Systemic pro-hemostatic effect of sympathicomimetics with agonistic effects on alfa-adrenergic and/or beta-adrenergic receptors of the sympathetic nervous system, related to improved clot strength

ABSTRACT

The present invention relates to a novel use and methods of treatment using sympathicomimetic agonists with pro-hemostatic activity.

REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.12/681,352, filed Sep. 2, 2010, which is a U.S. National Phaseapplication of PCT/DK2008/050242, filed Oct. 1, 2008, which claimspriority to Danish application No. PA200701418, filed Oct. 2, 2007. Theentire content of each application is incorporated herein by reference.All patent and non-patent references cited in the application, or in thepresent application, are also hereby incorporated by reference in theirentirety.

FIELD OF THE INVENTION

The present invention relates to a novel use and methods of treatmentusing sympathicomimetic agonists with pro-hemostatic activity.

BACKGROUND OF THE INVENTION

Blood coagulation is a process consisting of a complex interaction ofvarious blood components (or factors) that eventually gives rise to afibrin clot [Roberts et al. 2006]. Generally, the blood components,which participate in what has been referred to as the coagulation“cascade”, are enzymatically inactive proteins (proenzymes or zymogens)that are converted to proteolytic enzymes by the action of an activator(which itself is an activated clotting factor). Coagulation factors thathave undergone such a conversion are generally referred to as “activefactors”, and are designated by the addition of the letter “a” to thename of the coagulation factor (e.g. Factor VIIa). Initiation of thehemostatic process is mediated by the formation of a complex betweentissue factor, exposed as a result of injury to the vessel wall, andFactor VIIa [Roberts et al. 2006]. This complex then converts Factors IXand X to their active forms. Factor Xa converts limited amounts ofprothrombin to thrombin on the tissue factor-bearing cell. Thrombinactivates platelets and Factors V and VIII into Factors Va and VIIIa,both cofactors in the further process leading to the full thrombinburst. This process includes generation of Factor Xa by Factor IXa (incomplex with factor VIIIa) and occurs on the surface of activatedplatelets. Thrombin finally converts fibrinogen to fibrin resulting information of a fibrin clot. In recent years Factor VII and tissue factorhave been found to be the main initiators of blood coagulation.

It is often desirable to stimulate or improve the coagulation competencein a subject to control bleeding disorders that have several causes suchas clotting factor deficiencies (e.g. hemophilia A and B or deficiencyof coagulation Factors XI or VII) or clotting factor inhibitors [Singhet al. 2007] and also to control excessive bleeding occurring insubjects with a normally functioning blood clotting cascade (no clottingfactor deficiencies or inhibitors against any of the coagulationfactors). Such bleeding may, for example, be caused by a defectiveplatelet function, thrombocytopenia or von Willebrand's disease [Brace2007]. Bleeding is also a major problem in connection with surgery andother forms of tissue damage [Vaslev et al. 2002, Hardy et al. 2005].

In order to control the bleeding for example in connection with surgeryor trauma a multifaceted treatment of the bleeding is initiated,including the below examples of treatments which are performed eitheralone or in combination:

-   -   1. Surgical hemostatic techniques by diathermia, clamping,        sutures or packaging,    -   2. Administration of blood products such as red blood cells        (RBC), plasma, containing coagulation factors and platelets,    -   3. Endovascular treatment (coiling),    -   4. Local hemostatic compounds including fibrin glue, pads with        thrombin and other coagulation factors, local injection of        vasoconstrictors,    -   5. Pro-hemostatic pharmaceuticals such as recombinant factor        VIIa, recombinant factor XIIIa, and factor concentrates either        produced from human plasma or by recombinant technique for FVIII        and FIX,    -   6. Antifibrinolytic pharmaceuticals such as aprotinin,        tranexamic acid and others [Cheung et al. 2007].

Pivotal for many of these medical treatments and procedures are theadministration of allogenic blood products [Ferraris et al. 2007].However, administration of allogenic blood products is associated withdevelopment of transfusion related complications such as:

-   -   a) intravascular hemolytic transfusion reaction,    -   b) delayed hemolytic transfusion reaction,    -   c) transfusion related acute lung injury (TRALI),    -   d) transfusion transmitted infections by virus (HTLV, HIV 1, 2,        Hepatitis B, C, CMV) or bacteria,    -   e) transfusion associated graft versus host reaction (TA-GVHD),    -   f) posttransfusions purpura (PTP) [Stainsby et al. 2006].

In addition, transfusion of allogenic blood products is also associatedwith immunomodulation and immunosuppression predisposing for thedevelopment of postoperative infections as reported in orthopedic, burnand colorectal surgery [Banbury et al. 2006, Jeschke et al. 2007,Milasiene et al. 2007]. Furthermore, it has been reported by severalgroups that administration of blood products is independently associatedwith an increase in development of multiorgan failure [Zallen et al1999] and mortality [Herbert et al. 1999, Engoren et al. 2002, Karkoutiet al. 2004]. In fact, administration of red blood cells to patientsundergoing surgical revascularization of coronary arteriesdose-dependently is associated with increased 5 year mortality [Engorenet al. 2002]. In addition, transfusion of blood products may result inmicrochimerism with the immunocompetent donor leukocytes survivingindefinitely in the recipient [Reed et al. 2007].

Accordingly, in treatment of bleeding episodes, e.g. due to trauma,surgery or other medical treatments, the above-mentioned hazards ofallogenic blood transfusion and the increasing shortage of allogenicblood donors and hence shortage of blood products calls for new optionsfor pro-hemostatic treatments that improve the subjects clotting abilityand hence reduce the bleeding and the need for allogenic bloodtransfusion in these subjects, without compromising the safety of therecipient.

In order to reduce blood loss locally, vasoconstrictors such asadrenaline and noradrenaline have been used either alone or incombination with any of the above-mentioned treatment alternatives. Bylocal administration of vasoconstrictors the peripheral blood vesselsare constricted whereby blood loss is reduced. By local administration,the systemic effects normally associated with vasoconstrictors areavoided, such as, for example, elevated systemic blood pressure and thusincreased blood loss through open vessels.

Several reports exist on the use of vasoconstrictors as local hemostaticagents. For example in US 2007/0073210 is disclosed a wound dressingcomprising a vasoconstrictive medicinal substance, such as adrenaline,as a ready to use product for local treatment of bleeding wounds.

Local administration of vasoconstrictors, such as adrenaline andnoradrenaline, to a hemodialysis site in order to reduce complicationsassociated with hemodialysis therapy is disclosed in US Publication No.2005/0075597.

In WO2001/82937 compositions of intermacromolecular complexes such as,e.g. polyether, polyacids and polyalkylene and methods for making andusing such compositions in reducing post-surgical bleeding is described.The application further describes the incorporation of vasoconstrictorsin these compositions in order to have a local drug delivery at asurgical site.

Furthermore, the use of vasoconstrictors in a method to controlgastrointestinal bleeding when injected directly into the peritonealcavity or intragastrically is described U.S. Pat. No. 4,337,573. By thismethod, a local effect is obtained without any unwanted systemic effectsbecause the vasoconstrictors are absorbed into the portal system andinactivated before entering systemic circulation.

In all these cited reports use is made of the vasoconstrictor effects ofe.g. adrenaline and noradrenaline on the peripheral blood vessels bylocal administration in order to reduce bleeding.

SUMMARY OF THE INVENTION

The inventors of the present invention have surprisingly found thatsystemic administration of sympathicomimetic agonists such as adrenalineand noradrenaline in low doses (100 to a 1000 times lower than in thecurrent indications i.e. cardiac arrest, anaphylactic shock) will resultin a systemic activation of the coagulation system, while at the sametime avoiding the side effects such as elevated blood pressure, and thusincreased blood loss through open vessels, that would counteract thebenefits of the treatment. By administration of low doses of systemicsympathicomimetic agonists a faster and stronger thrombin generationwill take place, which will result in faster clot formation, a strongerand more durable clot, which is more resistant to shear and fibrinolyticenzymes. As a consequence of this, the systemic treatment withsympathicomimetic agonists such as adrenaline, noradrenaline, dopamine,dobutamine and ephedrine etc. in low doses are contemplated to reducebleeding and/or risk of bleeding.

As will be described in further detail in the below, the inventorsenvisage that any sympathicomimetic substance, including adrenaline andnoradrenaline, can be used in the present invention.

Thus, one object of the present invention relates to a previouslyunrecognized effect of sympathicomimetic agonists having pro-hemostaticactivity related to improved clot strength when administeredsystemically by way of intravenous, intramuscular or subcutaneous,intrapulmonary, intra-alveolarly, oral, sublingual, mucosal, or rectalroutes as well as any nucleic acid constructs encoding such agonists,vectors and host cells comprising and expressing the nucleic acid,pharmaceutical compositions, uses and methods of treatment.

The present invention relates to novel uses and methods of treatmentusing sympathicomimetic agonists with pro-hemostatic activity resultingin improved clot strength, as well as nucleic acid constructs encodingsuch sympathicomimetic agonists, vectors and host cells comprising andexpressing the nucleic acid and pharmaceutical compositions.

Thus an object of the present invention relates to an adrenergicreceptor agonist for systemic administration for the treatment and/orprophylaxis of bleeding in a subject.

Another object of the present invention relates to novel uses andmethods of treatment using sympathicomimetic agonists withpro-hemostatic activity in combination with compounds capable ofblocking or minimizing any adverse effects that may be elicited byadministration of the sympathicomimetic agonists. Such inhibitorycompounds include blockers of the adrenergic receptors and specificallyblockers of the beta subtype of the adrenergic receptors.

Another object of the present invention thus relates to a compositioncomprising an adrenergic receptor agonist and a beta blocker for thetreatment or prophylaxis of bleeding in a subject.

A third object of the present invention relates to novel uses andmethods of treatment using sympathicomimetic agonists withpro-hemostatic activity in combination with potassium in order tomaintain serum potassium concentrations upon administration of thesympathicomimetic agonists alone or in combination with the adrenergicreceptor blockers.

A third object of the present invention thus relates to a compositioncomprising an adrenergic receptor agonist, potassium in apharmaceutically acceptable form and optionally a beta blocker for thetreatment or prophylaxis of bleeding in a subject.

Additional aspects of the present invention and particular embodimentswill be apparent from the description below as well from the appendedclaims.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1: TEG technology.

FIG. 2: TEG parameters.

FIG. 3: Representative TEG profile of healthy volunteers before andafter administration of sympathicomimetics agonists.

FIGS. 4 a, b, and c: TEG parameters (4 a) R, (4 b) Angle and (4 c) MA of30 healthy volunteers after totally 15 minutes of i.v. administration ofadrenaline.

FIG. 5: TEG MA measured before and after i.v. infusion of noradrenalineat 4.8 μg/kg/h for 15 minutes in 10 healthy volunteers.

FIG. 6: TEG MA measured before (t=0) and after i.v. infusion ofadrenaline at 4.8 μg/kg/h for 15 minutes (t=15) and 30 minutes afterdiscontinuation of adrenaline administration (t=45).

FIGS. 7 a, b and c: TEG parameters (7 a) R, (7 b) Angle and (7 c) MAfrom blood samples collected from patients infused with adrenaline priorto prostatectomy.

FIG. 8: Intra-operative bleeding (in ml) of the patients of FIG. 7(receiving adrenaline in the step-wise doses 1, 2 and 3 μg/kg/h) and 10other prostatectomy patients receiving a 15 minutes continuousadrenaline infusion of 3 μg/kg/h.

FIGS. 9 a and b: (9 a) A representative example of TEG tracings with tPAinduced fibrinolysis before and immediately after infusions ofadrenaline. (9 b) Statistic comparisons of the lysis AUC (area under thecurve).

FIG. 10: Administration of adrenaline and adrenaline and seloken to 7healthy volunteers.

FIGS. 11 a, b, c, d, and e: The volunteers of FIG. 10 were monitoredhaemodynamically at the same time points as described in FIG. 10: (11 a)heart rate (HR), (11 b) cardiac output (CO), (11 c) stroke volume (SV),(11 d) invasive blood pressure: mean arterial pressure, MAP) and (11 e)total peripheral resistance (TPR).

FIG. 12 shows three healthy volunteers received 5 doses of adrenalineinfusion lasting for 5 minutes each in the following step-wiseincreasing doses 1, 3, 5, 7, and 9 μg/kg/h. After resting 1 hour, thesubjects received Seloken i.v. 0.20 μg/kg for 10 minutes and restedagain 30 minutes before repeating the step-wise adrenaline infusions.Blood samples were obtained from an arterial catheter at baseline (0.0μg/kg/h)), after each of the first adrenaline doses, at baseline afterSeloken administration and rest and after each of the subsequentadrenaline infusions. The blood was analyzed with TEG as described inFIG. 3 and Example 1. TEG MA values are presented as mean with 95% CI.

DETAILED DESCRIPTION OF THE INVENTION

It has for many years been known that endogenous sympathetic activationsecondary to a stress response results in an increase in procoagulantfactors, platelet activation as well as in markers of increasedfibrinolysis [Cannon et al. 1914]. Extensive research in athletes havecorroborated that physical exercise results in increased levels ofcirculating sympathetic transmitters and that this is associated with anincreased level of activated coagulation factors as well as increasedfibrinolysis [Colman et al. 2001].

As mentioned above, sympathicomimetic agonists have been used for aconsiderable time as a local hemostatic agents due to their well-knownvasoconstricting effects on the vasculature whereby bleeding can bereduced through contraction of the peripheral blood vessels.

Due to the effect of these sympathicomimetic agonists on heart rate,blood pressure, anxiety and redistribution of blood flow, no attemptshave, to the inventors knowledge, been performed to stop or preventbleeding episodes by systemic administration, because at the recommendeddoses the agonists will cause increased heart rate and blood pressurelevels, anxiety and ventricular arrhythmia which together with theincreased blood loss through open vessels is unacceptable in themajority of patients.

The inventors of the present invention have surprisingly found that thesympathicomimetic agonists activate the hemostatic system and improveclot strength and stability. By systemic administration of low doses(100 to a 1000 times lower than current indications) ofsympathicomimetic agonists no significant elevation of the bloodpressure is experienced and thereby blood loss due to this effect isabsent, whereas the pro-hemostatic effect on the coagulation systemprevails. Besides adrenaline, administration of e.g. othersympathicomimetic agonists such as noradrenaline, dopamine, dobutamine,ephedrine etc. (see herein below) is contemplated to lead to a systemicactivation of the coagulation system, and importantly, to an improvedhemostatic ability in humans due to improved clot strength. Themechanical strength of the clot is the determining factor for whetherhemostasis can be achieved, since the strength of the clot determines ifit can resist the shear forces of the flowing blood [Kawasaki et al2004, Fries et al. 2006, Velik-Salchner et al. 2007, Bassus et al. 2006,Sorensen et al. 2005, Tomokiyo et al. 2003].

Interestingly, despite the speed, strength and durability of the clotformation, thrombosis does not occur more frequently with the agents ofthe present invention than without administration of the agents. Thismay in part be due to the fact that the sympathicomimetic agonists suchas adrenaline and noradrenaline quickly, as in within minutes, arecleared from the body. Thus, the effects of the sympathicomimeticagonists are halted within minutes of termination of administration, andthe hemostatic equilibrium of the particular subject is returned to itsusual level. Furthermore, the clot is not after formation a permanentfeature, the equilibrium between coagulation and fibrinolysis ischanged, due to the increased speed of formation and longer durabilityof the clot following adrenaline administration, but there still isequilibrium between coagulation and fibrinolysis.

The advantages of the present invention are several fold: for theindividual subject treated less blood is lost and thus less, if any,blood and/or blood products need be administered. Thus is beneficial tothe subject as a reduced blood loss lessens the stress on the bodilysystems of the subject and adverse effects known to medicalpractitioners and others skilled in the art that may follow fromreceiving blood and/or blood products are avoided and/or minimized.Obviously, with no or only a fraction of the blood/blood products usedfor a given procedure, money is saved and thus the administration ofsympathicomimetic agonists has an economic incentive as well.

The term “activity” is intended to mean the ability to generate a clotof improved stability as well as an increased initiation, amplificationand propagation of the hemostatic system, resulting in a fasterformation of a clot of greater mechanical strength and stabilitytogether with increased resistance to fibrinolysis as compared to whenthe agonists are not administered.

The clinical importance of clot strength for hemostasis has further beenillustrated in postoperative patients with ongoing bleedings, where anormalization of clot strength was associated with achievement ofhemostasis [Johansson P I. 2007]. Patients with reduced clot strength,as evidenced by a reduced TEG MA (TEG: thrombelastography, MA: maximalamplitude), where treated with infusion of platelets until anormalization of clot strength, i.e. TEG MA was found, correlating withachievement of hemostasis. See Example 1 for a review of the TEGtechnology.

It is therefore envisaged that systemic administration ofsympathicomimetic agonists, will be useful for treatment or prophylaxisof controlled or uncontrolled bleeding episodes in connection withvarious forms of e.g. trauma, surgery, post partum or due to congenitalor acquired bleeding conditions.

Administration of the sympathicomimetic agonists of the presentinvention increases clot strength and stability and may be used toincrease the clot strength and stability in a subject with subnormalclot strength and stability or may be used to increase clot strength andstability in a subject with normal clot strength and stability to ahigher degree of strength and stability. Thus, clot strength andstability is shifted to a more stable level following administration ofsympathicomimetic agonists. Preferably, the clot strength and stabilityafter administering the sympathicomimetic agonist(s) is kept within thenormal range of clot strength and stability but is either lifted from asubnormal level to within the normal range of clot strength andstability or is lifted from within the normal range of clot strength andstability towards the upper end of the normal range of clot stability.By staying within the normal range of clot strength and stabilitypossible adverse effects are not encountered. Thus it is an object ofthe present invention that the clot strength and/or stability byadministration of a sympathicomimetic agonist is shifted to the upperend of the normal range(s) of clot strength and/or stability.

The clot strength and stability and changes herein may be measured asincreases in relative clot strength by the TEG (Thrombelastography)measurable parameter MA and clot stability by the TEG derivableparameter Lysis AUC. The maximal amplitude (MA) parameter reflectsmaximal clot strength i.e. the maximal elastic modus of the clot. Thearea under the lysis curve, i.e. area under the curve from MA isobtained (Lysis AUC) reflects degree of fibrinolysis (see FIG. 2). Bothclot strength and stability may be measured, or one parameter only maybe followed during a procedure such as either the clot stability or theclot strength. It is an object of the present invention that the clotstrength measured by the MA increases relative to the MA prior toadministration of a sympathicomimetic agonist by 105%, such as by 110%,such as by 115%, such as by 120%, such as by 125%, such as by 130%, suchas by 135%, such as by 140%, such as by 145%, such as by 150%, such asby 155%, such as by 160%, such as by 165%, such as by 170%, such as by175%, such as by 180%, such as by 185%, such as by 190%, such as by195%, such as by 200% or more. Likewise it is an object of the presentinvention that the clot stability increases Lysis AUC. This parametermay with a TEG analysis be measured e.g. after addition of tissueplasminogen activator (tPA), and thus it is an object of the presentinvention that the clot stability measured by the Lysis AUC increasesrelative to the Lysis AUC prior to administration of a sympathicomimeticagonist by 105%, such as by 110%, such as by 115%, such as by 120%, suchas by 125%, such as by 130%, such as by 135%, such as by 140%, such asby 145%, such as by 150%, such as by 155%, such as by 160%, such as by165%, such as by 170%, such as by 175%, such as by 180%, such as by185%, such as by 190%, such as by 195%, such as by 200% or more.

As follows from the above, disregarding which level of strength orstability is achieved, once the administration of the sympathicomimeticagonist stops, the levels will return to their pre-administrativelevels, due to the rapid break down/turn over of the sympathicomimeticagonist.

The term “bleeding disorder” used herein will reflect any defect,congenital, acquired or induced, of cellular or molecular origin that ismanifested in bleedings. The term “bleeding episodes” or “bleeding” ismeant to include any episode were bleeding of a magnitude necessitatingadministration of blood products may occur, including uncontrolled andexcessive bleeding both in connection with surgery and other forms oftissue damage in a subject.

A “subject” or “patient” includes humans and other mammals, and thus themethods are applicable to both human therapy and veterinaryapplications, in particular to human therapy. The term “mammal” includeshumans, non-human primates (e.g. baboons, orangutans, monkeys), mice,pigs, cows, goats, cats, rabbits, rats, guinea pigs, hamsters, horse,monkeys, sheep or other non-human mammal.

Treatment, as used in this application, is therefore intended to includeboth prevention of an expected bleeding, such as in surgery, andregulation of an already occurring bleeding, such as in trauma, with thepurpose of inhibiting or minimizing the bleeding. Prophylacticadministration of the variant according to the invention is thusincluded in the term “treatment”.

Sympathicomimetic Agonists

As apparent from the above, the treatment with sympathicomimeticagonists according to the present invention comprises adrenaline,noradrenaline, dobutamin, ephedrine, dopamine etc, see herein below.However, it is envisaged that the “sympathicomimetics” or“sympathicomimetic agonists” as used interchangeable herein, includesany pharmaceutical compounds with the same or similar activity asnoradrenaline (norepinephrine) and adrenaline (epinephrine). This groupof compounds, having predominantly peripheral action, can be dividedinto:

-   -   Directly acting sympathicomimetics that acts by stimulating the        receptors of the sympathetic nervous system, and    -   Indirectly acting sympathicomimetics that act by either        releasing transmitters from the prejunctional nerve ends or by        inhibiting their removal from the synaptic junction.

Directly acting sympathicomimetics act upon the adrenergic receptors(adrenoceptors), these comprising the α₁-, α₂-, β₁, β₂- and β₃-subtypes[Goldstein. 2006]. Any sympathicomimetic agonist is of relevance for thepresent invention for use in the treatment and/or prophylaxis ofbleeding in a subject. Such sympathicomimetic agonists include but arenot limited to agonists that are ligands of any one or more of theabovementioned receptors. Some sympathicomimetic agonists are specificfor one or more of the abovementioned receptors; for example aparticular agonist may be alpha-1 specific, or be alpha specificindicating that the agonist will bind either of the two known alphareceptors, or may be an agonist capable of interacting with any of theadrenergic receptors; an example hereof is adrenaline. Examples of allof these types of sympathicomimetic of relevance to the presentinvention include, but are not limited to: Adrenaline (epinephrine),Noradrenaline (norepinephrine), Phenylephrine, Methoxamine, Cirazoline,Xylometazoline, Methylnorepinephrine, Oxymetazoline, Dexmedetomidine,Clonidine, Lofexidine, Xylazine, Tizanidine, Guanfacine, Guanabenz,Guanoxabenz, Guanethidine, Methyldopa, amidephrine, amitraz,anisodamine, apraclonidine, brimonidine, cirazoline, detomidine,dexmedetomidine, ergotamine, etilefrine, indanidine, lofexidine,medetomidine, mephentermine, metaraminol (e.g. Aramine), methoxamine,midodrine, mivazerol, naphazoline, norfenefrine, octopamine,oxymetazoline, phenylpropanolamine, rilmenidine, romifidine, synephrine,talipexole and tizanidine, Dopamine (e.g. Intropine) Dobutamine,Dobutrex, Isoproterenol, Salbutamol (Albuterol in USA), Bitolterolmesylate, Formoterol, Isoprenaline, Levalbuterol, Metaproterenol,Salmeterol, Terbutaline, Ritodrine, Fenoterol, Clenbuterol, L-796568,Amibegron, Solabegron, arbutamine, befunolol,bromoacetylalprenololmenthane, broxaterol, cimaterol, cirazoline,denopamine, dopexamine, etilefrine, hexoprenaline, higenamine,isoetharine, isoxsuprine, mabuterol, methoxyphenamine, nylidrin,oxyfedrine, pirbuterol, prenalterol, procaterol, ractopamine,reproterol, rimiterol, ritodrine, tretoquinol, tulobuterol, xamoterol,and zinterol. Brand names of these compounds may vary from company tocompany and country to country; aliases of the abovementioned compoundsor other sympathicomimetic agonists are included within the scope of thepresent invention.

Preferably, compounds of the present invention for administration forprevention and/or treatment of bleeding in a subject comprises agonistsof the Alpha-1 adrenergic receptor, such as but not limited to:Adrenaline (epinephrine), Noradrenaline (norepinephrine), Phenylephrine,Methoxamine, Cirazoline, Xylometazoline Methylnorepinephrine, andOxymetazoline; as well as Alpha-2 adrenergic receptor agonists such as,but not limited to: Adrenaline (epinephrine), Noradrenaline(norepinephrine), Dexmedetomidine, Clonidine, Lofexidine, Xylazine,Tizanidine, Guanfacine, Guanabenz, Guanoxabenz, Guanethidine, andMethyldopa; and agonists that interact with both alpha receptors (and insome instances also the beta receptors), examples of these including,but again not being limited to: amidephrine, amitraz, anisodamine,apraclonidine, brimonidine, cirazoline, detomidine, dexmedetomidine,epinephrine, ergotamine, etilefrine, indanidine, lofexidine,medetomidine, mephentermine, metaraminol, methoxamine, midodrine,mivazerol, naphazoline, norepinephrine, norfenefrine, octopamine,oxymetazoline, phenylpropanolamine, rilmenidine, romifidine, synephrine,talipexole and tizanidine.

Likewise, examples of sympathicomimetic agonists that according to thepresent invention may be administered for the prevention and/ortreatment of bleeding in a subject are agonists that interact with thebeta receptors, these include, but are not limited to agonists that bindthe Beta 1 adrenergic receptor, such as, but not restricted to:Noradrenaline, Isoprenaline, Dobutamine, Dobutrex, and Isoproterenol (β1and β2); the Beta-2 adrenergic receptor agonists, again including butnot limited to: Salbutamol (Albuterol in USA), Bitolterol mesylate,Formoterol, Isoprenaline, Levalbuterol, Metaproterenol, Salmeterol,Terbutaline, Ritodrine, Fenoterol, Isoproterenol (β1 and β2), andClenbuterol; as well as the following non-limiting examples of agoniststhat bind the Beta-3 adrenergic receptor: L-796568, Amibegron,Solabegron, Noradrenaline, adrenaline, and isoprenaline; and thesympathicomimetic agonists that may bind either of the beta receptors(and in some cases also the alpha receptors), that list including butnot being restricted to: arbutamine, befunolol,bromoacetylalprenololmenthane, broxaterol, cimaterol, cirazoline,denopamine, dopexamine, epinephrine, etilefrine, hexoprenaline,higenamine, isoetharine, isoxsuprine, mabuterol, methoxyphenamine,nylidrin, oxyfedrine, pirbuterol, prenalterol, procaterol, ractopamine,reproterol, rimiterol, ritodrine, tretoquinol, tulobuterol, xamoterol,and zinterol.

Thus it is an object of the present invention to provide compounds,specifically agonists of the adrenergic receptors, herein also referredto as sympathicomimetic agonists for the prevention and/or treatment ofbleeding in a subject; examples of such compounds are given in theabove.

The agonistic substance may be any endogenous or exogenous agonisticsubstance affecting any one or more of the α₁, α₂, β₁, β₂, β₃ adrenergicreceptors. Furthermore, the agonistic substance may comprise any human,non-human, recombinant or by any other means manufactured agonisticsubstance affecting any one or more of the α₁, α₂, β₁, β₂, β₃ adrenergicreceptors of the sympathetic nerve system.

Preferably, sympathicomimetic agonists for the prevention and/ortreatment of bleeding in a subject include but are not limited toagonists capable of binding at least one adrenergic receptor subtype.

Most preferably the sympathicomimetic agonists for the prevention and/ortreatment of bleeding in a subject include but are not limited toadrenaline, noradrenaline, dobutamin, dobutrex, and dopamine, as well asmetabolic products and chemically related synthetic derivates hereof.

Thus, sympathicomimetic agonists may further include any agonist with anagonistic effect on α-adrenergic and/or β-adrenergic receptors,including any subtypes (e.g. α₁-, α₂-, β₁, β₂- and β₃-subtypes), of thesympathetic nervous system, such as but not limited to adrenaline,noradrenaline, dopamine, dobutamin, dobutrex, ephedrine and other knownor yet undiscovered chemical or biological substances or compounds whereany of the above mentioned are included.

The agonistic substance or derivatives hereof may also be in acombination of two or more, such as three or more, four or more and fiveor more of any of the sympathicomimetics agonist discussed above.

In a specific embodiment of the present invention, the sympathicomimeticagonists comprise adrenaline and/or noradrenaline and/or dobutamine.Analogs of these substances may also be useful in the present invention.

In a still further embodiment of the present invention, thesympathicomimetic agonist comprises or is adrenaline (epinephrine).

In a still further embodiment of the present invention, thesympathicomimetic agonist comprises or is noradrenaline(norepinephrine).

The terms adrenaline and epinephrine are used interchangeably herein andboth denote the compound defined in formula I with IUPAC name:(R)-4-(1-hydroxy-2-(methylamino)ethyl)benzene-1,2-diol:

Likewise, the terms noradrenaline and norepinephrine are usedinterchangeably herein and both denote the compound defined in formulaII with IUPAC name: 4-(2-Amino-1-hydroxyethyl)benzene-1,2-diol:

Any sympathicomimetic able of inducing an activation of the hemostaticsystem equal to the 3 microgram/kg/hour of adrenaline is contemplated toinduce a significant pro-hemostatic effect. Thus, a method for testingthe hemostatic efficacy and/or the required dose of a sympathicomimeticagonist comprises the following steps:

-   -   a) administering to a subject and/or to a blood sample taken        from a subject a sympathicomimetic agonist to be tested,    -   b) conducting a TEG analysis on a blood sample from the subject,    -   c) comparing the at least one measured parameter such as but not        limited to: r value (clotting time), k value (clot kinetics),        Angle or alpha (representing velocity of clot formation) MA,        maximal amplitude, (the maximal physical clot strength), Lysis        AUC (the area under the fibrinolysis curve AUC) and/or        fibrinolysis time (LY) with the same one or more parameters        following the administration of 3 microgram/kg/hour of        adrenaline,        wherein the parameters obtained for the 3 microgram/kg/hour of        adrenaline may be obtained from the same subject being tested        with the sympathicomimetic agonist or a reference        value/parameter obtained in advance.

By reference value is understood a value that has been obtained afterrepeated testing of the effects of administering 3 microgram/kg/hour ofadrenaline to a statistically relevant number of subjects. The referencevalue may alternatively be based on the effects of administering anotherconcentration of adrenaline, such as but not limited to: between 1microgram/kg/hour of adrenaline and 10 microgram/kg/hour of adrenaline,dependent upon which effect is desired to be achieved by thesympathicomimetic agonist.

The method for testing the hemostatic efficacy and/or the required doseof a sympathicomimetic agonist may optionally comprise an additionalstep relating to from where the blood sample from the subject iscollected, namely whether it is collected from an artery or a vein anddependent hereon, the sample(s) on which the reference value(s) is/arebased must have been collected from the same arterial or venous sourceto ensure accuracy.

Thus, in one aspect of the present invention the blood sample to beanalyzed and the sample or samples (such as those on which a referencevalue is based) with which it is compared are all drawn from arterialblood.

In another aspect of the present invention the blood sample to beanalyzed and the sample or samples (such as those on which a referencevalue is based) with which it is compared are all drawn from venousblood.

Therefore it follows that the method for testing the hemostatic efficacyand/or the required dose of a sympathicomimetic agonist may furthercomprise the following steps:

-   -   a) administering to a subject and/or to a venous or arterial        blood sample taken from a subject a sympathicomimetic agonist to        be tested,    -   b) conducting a TEG analysis on a blood sample from the subject,    -   c) comparing the at least one measured parameter such as but not        limited to: r value (clotting time), k value (clot kinetics),        Angle or alpha (representing velocity of clot formation) MA,        maximal amplitude, (the maximal physical clot strength), Lysis        AUC (the area under the fibrinolysis curve AUC) and/or        fibrinolysis time (LY) with the same one or more parameters        following the administration of 3 microgram/kg/hour of        adrenaline as measured on a venous or arterial blood sample, the        sample being drawn from the same source as in a) wherein the        parameters obtained for the 3 microgram/kg/hour of adrenaline        may be obtained from the same subject being tested with the        sympathicomimetic agonist or a reference value/parameter        obtained in advance.

By reference value is understood a value that has been obtained afterrepeated testing of the effects of administering 3 microgram/kg/hour ofadrenaline to a statistically relevant number of subjects.

Preferably, a sympathicomimetic agonist of the present invention is asubstance capable of altering one or more of the TEG measurableparameters of the blood of a subject to which the substance isadministered such as: lowering the r value (clotting time), lowering thek value (clot kinetics), increasing the Angle or alpha (representingvelocity of clot formation), and/or increasing the MA, maximalamplitude, (the maximal physical clot strength), increasing the LysisAUC (the area under the fibrinolysis curve AUC) and/or increasing thefibrinolysis time (LY). Preferably, a sympathicomimetic agonist of thepresent invention is a substance capable of altering one or more of theTEG measurable parameters of the blood of a subject to which thesubstance is administered such as lowering the r value (clotting time),lowering the k value (clot kinetics), increasing the Angle or alpha(representing velocity of clot formation), and/or increasing the MA,maximal amplitude, (the maximal physical clot strength). Mostpreferably, a sympathicomimetic agonist of the present invention is asubstance capable of altering all of the following TEG measurableparameters of the blood of a subject to which the substance isadministered by lowering the r value (clotting time), lowering the kvalue (clot kinetics), and increasing the MA, maximal amplitude, (themaximal physical clot strength).

In this manner it has been found, that noradrenaline may be administeredin the same dose interval as adrenaline, and dopamine at a dose of10-100× higher (for example 30-300 microgram/kg/hour) than adrenalineand noradrenaline, and dobutamin may be administered at a dose of10-100× higher (for example 30-300 microgram/kg/hour) than adrenalineand noradrenaline.

Beta Blockers

A current indication for which adrenaline is used is for the treatmentcardiac arrest, anaphylactic shock and other cardiac dysrhythmiasresulting in diminished or absent cardiac output. The action ofadrenaline is to increase peripheral resistance via α1-adrenoceptorvasoconstriction, so that blood is shunted to the body's core, and theβ1-adrenoceptor response which is increased cardiac rate and output (thespeed and pronouncement of heart beats) resulting in amongst others:high blood pressure. The consequence of especially the beta-1 mediatedresponse: increased cardiac rate, cardiac output and high bloodpressure, is detrimental to subjects that are bleeding, as this willincrease the rate with which blood is being pumped out of the body.Surprisingly, the inventors of the present invention have found, thatadministration of adrenaline at doses 100-1000 times lower than thedoses administered for the treatment of cardiac arrest increases thehemostatic ability of the blood. If dysrhythmias, and especiallytachycardia, never the less are sought prevented, an aspect of thepresent invention comprising the co-administration of asympathicomimetic agonist with a beta-1 blocker accommodates this.

For example, adrenaline and other sympathicomimetic agonists comprisethe pro-hemostatic properties whereas the beta-1 blocker attenuates theagonist's effect on myocardial excitability, including development oftachycardia/tachyarrhythmia while preserving cardiac output as well asmaintaining unaltered blood pressure. The combination of adrenaline oranother sympathicomimetic agonist and a beta-1 receptor blocker enablesan improved pro-hemostatic response than possible by adrenaline alone,due to blockade of the unwanted side effects of adrenaline as outlinedabove.

In order to avoid any possibility of increasing the subjects' bloodpressure or inducing any other unwanted systemic or local reactions, anembodiment of the present invention relates to the administration of asympathicomimetic agonist in combination with a compound capable ofblocking the actions of the beta adrenergic receptors, i.e. a betablocker for the prevention and/or treatment of bleeding in a subject.

Beta blockers (sometimes written as β-blocker) are a class of drugs wellknown to those skilled in the art that used for various indications, butparticularly for the management of cardiac arrhythmias andcardioprotection after myocardial infarction (heart attack). Betablockers inhibit these normal epinephrine-mediated sympathetic actions,but have minimal effect on resting subjects. That is, they reduce theeffect of excitement/physical exertion on heart rate and force ofcontraction, dilation of blood vessels and opening of bronchi, and alsoreduce tremor and breakdown of glycogen. It is therefore expected thatnon-selective beta blockers have an antihypertensive effect. Theantihypertensive mechanism appears to involve reduction in cardiacoutput (due to negative chronotropic and inotropic effects), reductionin renin release from the kidneys, and a central nervous system effectto reduce sympathetic activity (for those β-blockers that do cross theblood-brain barrier, e.g. Propranolol). Beta blockers are also known asbeta-adrenergic blocking agents, beta-adrenergic antagonists, or betaantagonists.

As stated above, there are three known types of beta adrenergicreceptors and any compound capable of blocking the action of one or moreof these is of relevance to the present invention. Examples of betablockers that may be used in combination with a sympathicomimeticagonist for the prevention and/or treatment of bleeding in a subjectinclude, but are not limited to: Acebutolol, Alprenolol, Amosulalol,Arotinolol, Atenolol, Befunolol, Betaxolol, Bevantolol, Bisoprolol,Bopindolol, Bucindolol, Bunitrolol, Bupranolol, Butaxamine, Carazolol,Carteolol, Carvedilol, Celirolol, Esmolol (Brevibloc), Indenolol,Labetalol, Landiolol, Levobetaxolol, Levobunolol, Mepindolol,Metipranolol, Metoprolol (Seloken), Nadolol, Nebivolol, Nipradilol,Oxprenolol, Penbutolol, Pindolol, Propranolol, Sotalol, Talinolol,Tertalolol, Tilisolol, and Timolol and other known or yet undiscoveredchemical or biological substances or compounds where any of the abovementioned are included. Brand names of these compounds may vary fromcompany to company and country to country; aliases of the abovementionedcompounds or other beta blockers are included within the scope of thepresent invention.

An aspect of the present invention relates to the administration of asympathicomimetic agonist in combination with a beta blocker for theprevention and/or treatment of bleeding in a subject, the beta blockerbeing a non-selective agent (i.e. may bind or block the action of morethan one beta adrenergic receptor), such as, but not restricted to:Alprenolol, Carteolol, Levobunolol, Mepindolol, Metipranolol, Nadolol,Oxprenolol, Penbutolol, Pindolol, Propranolol, Sotalol, and Timolol.

Another aspect of the present invention relates to the administration ofa sympathicomimetic agonist in combination with a beta blocker for theprevention and/or treatment of bleeding in a subject, the beta blockerbeing a selective agent (i.e. an agent that binds to or block the actionof a specific beta adrenergic receptor) such agents comprising but notbeing limited to: β1-Selective agents such as Acebutolol, Atenolol,Betaxolol, Bisoprolol, Esmolol, Metoprolol (Seloken), Nebivolol,Amosulalol, Landiolol, and Tilisolol; or β2-Selective agents such asButaxamine; or beta 3 selective agents.

The most preferred beta blocker is a beta-1 receptor blocker with a highcardioselectivity (i.e. β₁/β₂ ratio) limiting the blockade to the beta-1receptor. The manner of calculating the cardioselectivity of a compoundis known to the person skilled in the art. Generally, it is therelationship between a given compounds affinity for the beta-1 andbeta-2 receptor, with a high affinity for the beta-1 receptor (i.e.higher than the affinity for the beta-2 receptor) being preferred.Furthermore the chosen beta-1 receptor blocker has a T½ (half life) of3-9 min enabling full blocker effect after administration of a loadingdose for 1-3 min and likewise the effect is rapidly reversible afterdiscontinuation. Thus the most preferred beta blocker to be used incombination with a sympathicomimetic agonist for the prevention and/ortreatment of bleeding in a subject may be chosen from the β1 (beta1)-Selective agents such as Acebutolol, Atenolol, Betaxolol, Bisoprolol,Esmolol, Metoprolol (Seloken), Nebivolol, Amosulalol, Landiolol, andTilisolol.

Preferably, at least one beta blocker of above is used in combinationwith sympathicomimetic agonists which may include any agonist with anagonistic effect on α-adrenergic and/or β-adrenergic receptors,including any subtypes (e.g. α₁-, α₂-, β₂- and β₃-subtypes), of thesympathetic nervous system, such as but not limited to adrenaline,noradrenaline, dopamine, dobutamin, dobutrex, ephedrine and other knownor yet undiscovered chemical or biological substances or compounds whereany of the above mentioned are included.

The beta blockers or derivatives hereof may also be in a combination oftwo or more, such as three or more, four or more and five or more of anyof the beta blockers discussed above.

In a specific embodiment of the present invention, the sympathicomimeticagonists comprise adrenaline and/or noradrenaline and/or dobutamine andare administered in combination with at least one beta blocker such asbut not limited to a non-selective agent (i.e. may bind or block theaction of more than one beta adrenergic receptor), such as, but notrestricted to: Alprenolol, Carteolol, Levobunolol, Mepindolol,Metipranolol, Nadolol, Oxprenolol, Penbutolol, Pindolol, Propranolol,Sotalol, and Timolol.

In another specific embodiment of the present invention, thesympathicomimetic agonists comprise adrenaline and/or noradrenalineand/or dobutamine and are administered in combination with at least onebeta blocker such as but not limited to β1-selective agents such asAcebutolol, Atenolol, Betaxolol, Bisoprolol, Esmolol, Metoprolol(Seloken), Nebivolol, Amosulalol, Landiolol, and Tilisolol; orβ2-Selective agents such as Butaxamine; or beta 3 selective agents.

Most preferably, the sympathicomimetic agonists comprise adrenalineand/or noradrenaline and/or dobutamine and are administered incombination with at least one beta blocker with a high cardioselectivity(i.e. β₁/β₂ ratio) and low half life such as but not limited to Seloken,Esmolol and Landiolol.

In a specific embodiment of the present invention, the sympathicomimeticagonists comprise adrenaline and/or noradrenaline and/or dobutamine andthe beta blocker is Seloken and/or Esmolol and/or Landiolol. Theadrenaline and/or noradrenaline and/or dobutamine and Seloken and/orEsmolol and/or Landiolol are administered to prevent or treat bleedingin a subject.

In a still further embodiment of the present invention, thesympathicomimetic agonist comprises or is adrenaline and is administeredin combination with Seloken.

In a still further embodiment of the present invention, thesympathicomimetic agonist comprises or is adrenaline and is administeredin combination with Landiolol.

In a still further embodiment of the present invention, thesympathicomimetic agonist comprises or is adrenaline and is administeredin combination with Esmolol.

In a still further embodiment of the present invention, thesympathicomimetic agonist comprises or is noradrenaline and isadministered in combination with Seloken.

In a still further embodiment of the present invention, thesympathicomimetic agonist comprises or is noradrenaline and isadministered in combination with Landiolol.

In a still further embodiment of the present invention, thesympathicomimetic agonist comprises or is noradrenaline and isadministered in combination with Esmolol.

The terms “used in combination”, “administered in combination with” or“co-administered” or “composition” indicate that the drugs may be areformulated together, or are kept as separate entities and may beadministered simultaneously or within a predetermined interval of eachother. Examples of how the sympathicomimetic agonists and beta blockersof the present invention may be administered in combination with eachother are given in the below.

The beta blocker of the present invention that is used in combinationwith a sympathicomimetic for the treatment of bleeding in a subject isadministered in the pharmaceutically efficient dose of the particularcompound. For example, Seloken may be administered in a tabletcomprising 50 mg to 200 mg of Seloken and an appropriate dosage of asympathicomimetic agonist as disclosed above. Alternatively; Seloken maybe administered parenterally at doses between 1 mg and 40 mgadministered in one or several dosages or intravenously at a rate of 10to 150 ml/hour (1 mg/ml). Likewise Esmolol (tradename Brevibloc) may beadministered at 0.1 to 5.0 mg/kg as an i.v. bolus injection, such as 0.5mg/kg and/or as between 0.01 to 1 mg/kg/min i.v., such as 0.05 to 0.3mg/kg/min as first administration or continued administration.Similarly, Landiolol may be administered intravenously at dosagesbetween 0.01 to 5 mg/kg/min, such as 0.1 to 0.5 mg/kg/min or as bolusinjections of between 1 mg to 20 mg. As is known to a person skilled inthe art, the dosage of beta blocker may be increased according thenecessity thereof.

Potassium (K)

Adrenaline is known to have a lowering effect on serum potassiumconcentrations. Normal reference values for potassium in plasma is:3.2-4.7 mmol/1 and in serum: 3.5-5.0 mmol/1. Mild hypokalaemia (lowconcentration of potassium in the blood) is defined as a plasmapotassium concentration >3.0 mmol/L and severe hypokalaemia is when thepotassium concentration is <3.0 mmol/L. Epinephrine in the doses to beadministered for the prevention and/or treatment of bleeding in asubject lowers the potassium concentration to approximately 3.3 mmol/1.and is thus not expected to cause hypokalaemia. Nevertheless, anembodiment of present invention comprises potassium at a concentrationof or in an amount corresponding to between 1 mmol/L to 30 mmol/L, or1.5 mmol/L to 25 mmol/L, or 2 mmol/L to 20 mmol/L, or 2.5 mmol/L to 15mmol/L, or 3 mmol/L to 10 mmol/L, or 4 mmol/L to 5 mmol/L. Preferably,potassium is comprised in an amount that counter the effect of thesympathicomimetic compound and thus retains the plasma potassiumconcentration within the normal range. The “normal range” may be thepharmaceutically/medically accepted range of potassium concentrationsfound in human beings or may be individualized so the plasmaconcentration of potassium measured in the individual prior tocommencement of treatment may be kept at the measured level.

An embodiment of the present invention relates to the administration ofa sympathicomimetic agonist in a formulation comprising potassium at aconcentration between 1 mmol/L and 30 mmol/L for the prevention and/ortreatment of bleeding in a subject.

Thus in one aspect, the treatment of bleeding in a subject comprises theadministration of at least one of the following sympathicomimeticagonists: adrenaline, noradrenaline, dopamine, dobutamin, dobutrex, andephedrine in combination with potassium at a concentration between 1mmol/L and 30 mmol/L. Most preferably, adrenaline and/or noradrenalineis administered in combination with potassium at a concentration ofbetween 1 mmol/L and 30 mmol/L.

Likewise, another embodiment of the present invention relates to theadministration of a sympathicomimetic agonist in combination with a betablocker in a formulation further comprising potassium at a concentrationbetween 1 mmol/L and 30 mmol/L for the prevention and/or treatment ofbleeding in a subject.

Thus in one aspect, the treatment of bleeding in a subject comprises theadministration of at least one of the following sympathicomimeticagonists: adrenaline, noradrenaline, dopamine, dobutamin, dobutrex, andephedrine in combination a beta blocker, the blocker preferably being abeta 1 receptor specific blocker and further being administered incombination with potassium at a concentration between 1 mmol/L and 30mmol/L. Most preferably, adrenaline and/or noradreline are administeredin combination with any one of the beta blockers seloken, esmolol,landiolol and/or propanolol and further in combination with potassium ata concentration of between 1 mmol/L and 30 mmol/L.

The administration of potassium may follow that of the administration ofthe sympathicomimetic agonist or be independent hereof. For instance,the administration of potassium may precisely follow the administrationof e.g. adrenaline such that the administration of potassium startsand/or stops with the administration of adrenaline.

For example: if the administration of adrenaline lowers the plasmapotassium concentration of the individual compared to normal levels orcompared to the level measured in the individual prior to adrenalineadministration, potassium may be administered to counter this loweringbringing the concentration of plasma potassium back to normal.Preferably, the administration of potassium stops at the same time asthe administration of the sympathicomimetic agonist and/or beta blocker.

Administration

Administration of the agonists is to be given to a subject resulting ina systemic concentration of the agonists. Methods of administrationinclude enteral, such as oral, sublingual, gastric or rectal and/orparenterally, that is by intravenous, intramuscular, subcutaneous,intranasal, intrapulmonary, intrarectal, intravaginal or intraperitonealadministration. The subcutaneous and intravenous forms of parenteraladministration are generally preferred. Appropriate dosage forms forsuch administration may be prepared by conventional techniques. Thecompounds may also be administered by inhalation that is by intranasaland oral inhalation administration. Appropriate dosage forms for suchadministration, such as an aerosol formulation or a metered doseinhaler, may be prepared by conventional techniques.

The compounds according to the invention may be administered with atleast one other compound. The compounds may be administeredsimultaneously, either as separate formulations or combined in a unitdosage form, or administered sequentially.

As used herein, “dose” shall mean any concentration of the agonistsadministered producing a pro-hemostatic effect on the hemostatic system.A dose sufficient to produce the desired effect in relation to theconditions for which it is administered, in particular an amount of asympathicomimetic agonists that is effective to stop, reduce or preventthe unwanted bleeding shall be described as the “effective dose”,“therapeutically effective dose” or “effective amount”. Normally thedose should be capable of preventing or lessening the severity or spreadof the condition or indication being treated. The exact dose will dependon the circumstances, such as the condition being treated, theadministration schedule, whether the sympathicomimetic agonists isadministered alone or in conjunction with another therapeutic agent oranother sympathicomimetic agonists, the plasma half-life of thesympathicomimetic agonists and the general health of the subject.

As will be understood by the person skilled in the art, amountseffective for this purpose will depend on the severity of the disease orinjury as well as the weight and general state of the subject. The doseis preferably given by the parenteral administration route, notably theintravenous, intramuscular and/or the subcutaneous, sublingual,trans-mucosal, intrapulmonal and intra-alveolar route. The dosages givenin the following is contemplated to be in the same order of magnitudeirrespective of the parenteral administration route.

For the sympathicomimetic agonists adrenaline and noradrenaline the doseadministered will for enteral and/or parenteral, notably oral,intravenous, intramuscular and/or subcutaneous routes, single orrepeated bolus dose(s) be in the range of from 0.1 μg/kg to about 50μg/kg, such as, e.g., from about 0.5 μg/kg to about 50 μg/kg, from about1 microgram/kg to 50 microgram/kg, such as e.g. 2 microgram/kg to 20microgram/kg, 2.5 microgram/kg to 15 microgram/kg, 3 microgram/kg to 14microgram/kg or 3.5 microgram/kg to 13 microgram/kg, or 4 microgram/kgto 12 microgram/kg, or 4.5 microgram/kg to 11 microgram/kg, or 5microgram/kg to 10 microgram/kg, or 5.5 microgram/kg to 9 microgram/kg,or 6 microgram/kg to 8 microgram/kg. Alternatively the parenteral,notably intravenous, intramuscular and/or subcutaneous routes, single orrepeated bolus dose(s) are in the range of from 0.01 microgram/kg to 100microgram/kg, such as 0.02 microgram/kg to 90 microgram/kg, such as 0.03microgram/kg to 80 microgram/kg, such as 0.04 microgram/kg to 70microgram/kg, such as 0.05 microgram/kg to 60 microgram/kg, such as 0.06microgram/kg to 50 microgram/kg, such as 0.07 microgram/kg to 40microgram/kg, such as 0.08 microgram/kg to 30 microgram/kg, such as 0.09microgram/kg to 27.5 microgram/kg, such as 0.1 microgram/kg to 25microgram/kg, such as 0.2 microgram/kg to 24 microgram/kg, such as 0.2microgram/kg to 23 microgram/kg such as 0.3 microgram/kg to 22microgram/kg, such as 0.4 microgram/kg to 21 microgram/kg, such as 0.5microgram/kg to 20 microgram/kg, such as 0.6 microgram/kg to 19microgram/kg, such as 0.7 microgram/kg to 18 microgram/kg, such as 0.8microgram/kg to 17 microgram/kg, such as 0.9 microgram/kg to 16microgram/kg, such as 1 microgram/kg to 15 microgram/kg. Alternatively,the interval may be between 1 microgram/kg to 20 microgram/kg, 1.5microgram/kg to 19.5 microgram/kg, such as 2 microgram/kg to 19microgram/kg, such as 2.5 microgram/kg to 18.5 microgram/kg, such as 3microgram/kg to 18 microgram/kg, such as 3.5 microgram/kg to 17.5microgram/kg, such as 4 microgram/kg to 17 microgram/kg, such as 4.5microgram/kg to 16.5 microgram/kg, such as 5 microgram/kg to 16microgram/kg, such as 5.5 microgram/kg to 15.5 microgram/kg, such as 6microgram/kg to 15 microgram/kg, such as 6.5 microgram/kg to 14.5microgram/kg, such as 7 microgram/kg to 14 microgram/kg, such as 7.5microgram/kg to 13.5 microgram/kg, such as 8 microgram/kg to 13microgram/kg, such as 8.5 microgram/kg to 12.5 microgram/kg, such as 9microgram/kg to 12 microgram/kg or any interval therein between.Alternatively, for the sympathicomimetic agonists adrenaline andnoradrenaline, the dose for parenteral administration, notablyintravenous infusion, will be in the range of from 1 microgram/kg to 10microgram/kg, or 1.5 microgram/kg to 9.5 microgram/kg, or 2 microgram/kgto 9 microgram/kg, or 2.5 to 8.5 microgram/kg, or 2.5 microgram/kg to8.5 microgram/kg, or 3 microgram/kg to 8 microgram/kg, or 3.5microgram/kg to 7.5 microgram/kg, or 4 microgram/kg to 7 microgram/kg orany interval therein between.

In an embodiment the sympathicomimetic agonists adrenaline andnoradrenaline the dose administered will for intravenous, intramuscularand/or subcutaneous single or repeated bolus dose is about 1microgram/kg.

In a specific embodiment the sympathicomimetic agonists adrenaline andnoradrenaline the dose administered will for intravenous, intramuscularand/or subcutaneous routes in a single or repeated bolus dose of about 2microgram/kg.

In a further embodiment the sympathicomimetic agonists adrenaline andnoradrenaline the dose administered will for intravenous, intramuscularand/or subcutaneous single or repeated bolus dose is about 3microgram/kg.

In a still further embodiment the sympathicomimetic agonists adrenalineand noradrenaline the dose administered will for intravenous,intramuscular and/or subcutaneous single or repeated bolus dose is about4 microgram/kg.

In a still further embodiment the sympathicomimetic agonists adrenalineand noradrenaline the dose administered will for intravenous,intramuscular and/or subcutaneous single or repeated bolus dose is about5 microgram/kg.

In a still further embodiment the sympathicomimetic agonists adrenalineand noradrenaline the dose administered will for intravenous,intramuscular and/or subcutaneous single or repeated bolus dose is about6 microgram/kg.

In a still further embodiment the sympathicomimetic agonists adrenalineand noradrenaline the dose administered will for intravenous,intramuscular and/or subcutaneous single or repeated bolus dose is about7 microgram/kg.

In a still further embodiment the sympathicomimetic agonists adrenalineand noradrenaline the dose administered will for intravenous,intramuscular and/or subcutaneous single or repeated bolus dose is about8 microgram/kg.

In a still further embodiment the sympathicomimetic agonists adrenalineand noradrenaline the dose administered will for intravenous,intramuscular and/or subcutaneous single or repeated bolus dose is about9 microgram/kg.

The bolus injection may be given once, twice or several times, forinstance, in keeping with the dosage administered the bolus injectionmay be given every 5 min (minutes), such as every 10 min, such as every15 min, such as every 20 min, such as every 25 min, such as every 30min, such as every 35 min, such as every 40 min, such as every 45 min,such as every 50 min, such as every 55 min, such as every 60 min such asevery 70 min, such as every 80 min, such as every 90 min, such as every100 min, such as every 110 min such as every 120 min or more. Forexample, the bolus dosage may be administered in the appropriateintervals from the time of trauma to the subject and until a treatmentfacility such as a hospital or other is reached.

The bolus injection may be followed by a maintenance dose. Such dosagesare described in the following; however, in specific embodiments, thefollowing dosages may also be used without any bolus injection. For thesympathicomimetic agonists adrenaline and noradrenaline, the dose forparenteral administration, notably intravenous infusion, will be in therange of from 0.01 microgram/kg/hour to 100 microgram/kg/hour, such as0.02 microgram/kg/hour to 90 microgram/kg/hour, such as 0.03microgram/kg/hour to 80 microgram/kg/hour, such as 0.04microgram/kg/hour to 70 microgram/kg/hour, such as 0.05microgram/kg/hour to 60 microgram/kg/hour, such as 0.06microgram/kg/hour to 50 microgram/kg/hour, such as 0.07microgram/kg/hour to 40 microgram/kg/hour, such as 0.08microgram/kg/hour to 30 microgram/kg/hour, such as 0.09microgram/kg/hour to 27.5 microgram/kg/hour, such as 0.1microgram/kg/hour to 25 microgram/kg/hour, such as 0.2 microgram/kg/hourto 24 microgram/kg/hour, such as 0.2 microgram/kg/hour to 23microgram/kg/hour such as 0.3 microgram/kg/hour to 22 microgram/kg/hour,such as 0.4 microgram/kg/hour to 21 microgram/kg/hour, such as 0.5microgram/kg/hour to 20 microgram/kg/hour, such as 0.6 microgram/kg/hourto 19 microgram/kg/hour, such as 0.7 microgram/kg/hour to 18microgram/kg/hour, such as 0.8 microgram/kg/hour to 17microgram/kg/hour, such as 0.9 microgram/kg/hour to 16microgram/kg/hour, such as 1 microgram/kg/hour to 15 microgram/kg/hour.Alternatively, the interval may be between 1 microgram/kg/hour to 20microgram/kg/hour, 1.5 microgram/kg/hour to 19.5 microgram/kg/hour, suchas 2 microgram/kg/hour to 19 microgram/kg/hour, such as 2.5microgram/kg/hour to 18.5 microgram/kg/hour, such as 3 microgram/kg/hourto 18 microgram/kg/hour, such as 3.5 microgram/kg/hour to 17.5microgram/kg/hour, such as 4 microgram/kg/hour to 17 microgram/kg/hour,such as 4.5 microgram/kg/hour to 16.5 microgram/kg/hour, such as 5microgram/kg/hour to 16 microgram/kg/hour, such as 5.5 microgram/kg/hourto 15.5 microgram/kg/hour, such as 6 microgram/kg/hour to 15microgram/kg/hour, such as 6.5 microgram/kg/hour to 14.5microgram/kg/hour, such as 7 microgram/kg/hour to 14 microgram/kg/hour,such as 7.5 microgram/kg/hour to 13.5 microgram/kg/hour, such as 8microgram/kg/hour to 13 microgram/kg/hour, such as 8.5 microgram/kg/hourto 12.5 microgram/kg/hour, such as 9 microgram/kg/hour to 12microgram/kg/hour or any interval therein between. Alternatively, forthe sympathicomimetic agonists adrenaline and noradrenaline, the dosefor parenteral administration, notably intravenous infusion, will be inthe range of from 1 microgram/kg/hour to 10 microgram/kg/hour, or 1.5microgram/kg/hour to 9.5 microgram/kg/hour, or 2 microgram/kg/hour to 9microgram/kg/hour, or 2.5 to 8.5 microgram/kg/hour, or 2.5microgram/kg/hour to 8.5 microgram/kg/hour, or 3 microgram/kg/hour to 8microgram/kg/hour, or 3.5 microgram/kg/hour to 7.5 microgram/kg/hour, or4 microgram/kg/hour to 7 microgram/kg/hour or any interval thereinbetween.

In an embodiment the intravenous infusion of the sympathicomimeticagonists adrenaline and noradrenaline will be about 1 microgram/kg/hour.

In a specific embodiment the intravenous infusion of thesympathicomimetic agonists adrenaline and noradrenaline will be about 2microgram/kg/hour.

In a further embodiment the intravenous infusion of thesympathicomimetic agonists adrenaline and noradrenaline will be about 3microgram/kg/hour.

In a still further embodiment the intravenous infusion of thesympathicomimetic agonists adrenaline and noradrenaline will be about 4microgram/kg/hour.

In a still further embodiment the intravenous infusion of thesympathicomimetic agonists adrenaline and noradrenaline will be about 5microgram/kg/hour.

In a still further embodiment the intravenous infusion of thesympathicomimetic agonists adrenaline and noradrenaline will be about 6microgram/kg/hour.

In a still further embodiment the intravenous infusion of thesympathicomimetic agonists adrenaline and noradrenaline will be about 7microgram/kg/hour.

In a still further embodiment the intravenous infusion of thesympathicomimetic agonists adrenaline and noradrenaline will be about 8microgram/kg/hour.

In a still further embodiment the intravenous infusion of thesympathicomimetic agonists adrenaline and noradrenaline will be about 9microgram/kg/hour.

The infusion may be of any duration necessary such as from 1 minute(min) to several hours if required. The dosage can, due to the rapidturnover of adrenaline and similar compounds be administeredcontinuously without risk of accumulation. Thus it is an object of theinvention to infuse a subject for the prophylaxis or treatment ofbleeding for more than 1 min such as 5 min, such as 10 min, such as 15min, such as 20 min, such as 25 min, such as 30 min, such as 35 min,such as 40 min, such as 45 min, such as 50 min, such as 55 min, such as60 min, such as 65 min, such as 70 min, such as 75 min, such as 80 min,such as 85 min, such as 90 min, such as 95 min, such as 100 min, such as105 min, such as 110 min, such as 120 min, such as 130 min, such as 140min, such as 150 min, such as 160 min, such as 170 min, such as 180 min,such as 190 min, such as 200 min, such as 210 min, such as 220 min, suchas 230 min, such as 240 min or more.

Any sympathicomimetic able of inducing an activation of the hemostaticsystem equal to the above mentioned dose of adrenaline and noradrenalinei.e. dopamine at a dose of 10-100× higher (30-300 microgram/kg/hour)than adrenaline and noradrenaline and dobutamin at a dose of 10-100×higher in (30-300 microgram/kg/hour) adrenaline and noradrenaline. Basedon this information it is contemplated that a person skilled in the artcan choose a proper dosage.

Single or multiple administrations of the compositions and combinationof sympathicomimetic agonists, beta blockers and/or potassium can becarried out with dose levels and patterns being selected by the treatingphysician.

The sympathicomimetic agonist and the beta blocker may beco-administered optionally in combination with potassium as soon as thesubject is asleep and the administration may be stopped after lastsuture.

The combination of sympathicomimetic agonist and beta blocker actsinstantaneously with regard to development of the pro-hemostaticresponse, and development of tachycardia/tacharrythmia is prevented byan initial loading dose of the beta blocker starting prior to theadministration of the sympathicomimetic agonist followed by a continuousinfusion. Thus, due to i.e. differences in turn over rate of thesympathicomimetic agonist and the beta blocker (the beta blocker in thefollowing example having the longer turn over rate) and optionally thepotassium may be administered such that the blocker is administered fora number of minutes (between 1 and 5 minutes) prior to administration ofthe sympathicomimetic agonist and likewise towards the end of thetreatment, the administration of the blocker is discontinued first, forexample 5 to 20 minutes before stopping the administration of thesympathicomimetic agonist. The potassium may be co-administered with thesympathicomimetic agonist.

Likewise, the pro-hemostatic effect of the sympathicomimeticagonist/beta blocker is abated within a well defined time afterdiscontinuation of the infusion and the administration of the blockerwill therefore be adjusted so the blockage of the cardiac beta receptorsis reversed when the haemodynamic effect of the sympathicomimeticagonist is abated. It will therefore be possible to discontinue theinfusion of the sympathicomimetic agonist/beta blocker, well before thesurgical procedure is finalized and bleeding has been controlled and thepro-hemostatic effect of the product will not be measurable by TEG MA30-60 min postoperatively.

In prophylactic applications, compositions containing thesympathicomimetic agonist of the invention are administered to a subjectsusceptible to or otherwise at risk of a disease state or injury toenhance the subject's own hemostatic capability. Such an amount isdefined to be a “prophylactically effective dose.” In prophylacticapplications, the precise amounts once again depend on the subject'sstate of health and weight, and it is anticipated that the dosegenerally will be as specified above.

The beta blockers of the present invention may be administered in thedosages recommended by the manufacturers or as are known to be efficientto those skilled in the art, i.e. medical practitioners.

Pharmaceutical Compositions of the Invention and its Use

The present invention also relates to a pharmaceutical compositioncomprising one or more sympathicomimetic agonists and one or morepharmaceutically acceptable carriers or exipients. Such pharmaceuticallyacceptable carrier or excipient as well as suitable pharmaceuticalformulation methods are well known in the art (see for exampleRemington: The Science and Practice of Pharmacy 1995, edited by E. W.Martin, Mack Publishing Company, 19th edition, Easton, Pa. In apreferred embodiments the sympathicomimetic variant are prepared in aparenteral composition. Such methods for preparing parenterallyadministrable compositions will also be known or apparent to thoseskilled in the art and are described in more detail in, for example,Remington's Pharmaceutical Sciences, 18th ed., Mack Publishing Company,Easton, Pa. (1990). As used herein, the term “pharmaceutical acceptable”means a carriers or excipients that does not cause any untoward effectsin subjects to whom it is administered.

Pharmaceutically Acceptable Salts

Pharmaceutically acceptable salts of the instant compounds, where theycan be prepared, are also intended to be covered by this invention.These salts will be ones which are acceptable in their application to apharmaceutical use. By that it is meant that the salt will retain thebiological activity of the parent compound and the salt will not haveuntoward or deleterious effects in its application and use in treatingdiseases.

Pharmaceutically acceptable salts are prepared in a standard manner. Ifthe parent compound is a base it is treated with an excess of an organicor inorganic acid in a suitable solvent. If the parent compound is anacid, it is treated with an inorganic or organic base in a suitablesolvent.

The compounds of the invention may be administered in the form of analkali metal or earth alkali metal salt thereof, concurrently,simultaneously, or together with a pharmaceutically acceptable carrieror diluent, especially and preferably in the form of a pharmaceuticalcomposition thereof, whether by oral, rectal, or parenteral (includingsubcutaneous) route, in an effective amount.

Examples of pharmaceutically acceptable acid addition salts for use inthe present inventive pharmaceutical composition include those derivedfrom mineral acids, such as hydrochloric, hydrobromic, phosphoric,metaphosphoric, nitric and sulfuric acids, and organic acids, such astartaric, acetic, citric, malic, lactic, fumaric, benzoic, glycolic,gluconic, succinic, p-toluenesulphonic acids, and arylsulphonic, forexample.

The compositions for parenteral administration comprise the agonist ofthe invention in combination with, preferably dissolved in, apharmaceutically acceptable carrier, preferably an aqueous carrier. Avariety of aqueous carriers may be used, such as water, buffered water,lactated Ringer's solution, saline, e.g. such as 0.7%, 0.8%, 0.9% or 1%,glycine such as 0.2%, 0.3%, 0.4% or 0.5% and the like. Normally, it isaimed that the composition has an osmotic pressure corresponding to a0.9% w/w sodium chloride solution in water. Moreover, as known by aperson skilled in the art, dependent on the specific administrationroute, pH may be adjusted within suitable ranges centered around pH 7.4.The compositions may be sterilized by conventional, well-knownsterilization techniques. The resulting aqueous solutions may bepackaged for use or filtered under aseptic conditions and lyophilized,the lyophilized preparation being combined with a sterile aqueoussolution prior to administration.

The compounds of the present invention may be formulated for parenteraladministration (e.g., by injection, for example bolus injection orcontinuous infusion) and may be presented in unit dose form in ampoules,pre-filled syringes, small volume infusion or in multi-dose containerswith an added preservative. The compositions may take such forms assuspensions, solutions, or emulsions in oily or aqueous vehicles, forexample solutions in aqueous polyethylene glycol. Examples of oily ornonaqueous carriers, diluents, solvents or vehicles include propyleneglycol, polyethylene glycol, vegetable oils (e.g., olive oil), andinjectable organic esters (e.g., ethyl oleate), and may containformulatory agents such as preserving, wetting, emulsifying orsuspending, stabilizing and/or dispersing agents. Alternatively, theactive ingredient may be in powder form, obtained by aseptic isolationof sterile solid or by lyophilisation from solution for constitutionbefore use with a suitable vehicle, e.g., sterile, pyrogen-free water.

Oils useful in parenteral formulations include petroleum, animal,vegetable, or synthetic oils. Specific examples of oils useful in suchformulations include peanut, soybean, sesame, cottonseed, corn, olive,petrolatum, and mineral. Suitable fatty acids for use in parenteralformulations include oleic acid, stearic acid, and isostearic acid.Ethyl oleate and isopropyl myristate are examples of suitable fatty acidesters.

Suitable soaps for use in parenteral formulations include fatty alkalimetal, ammonium, and triethanolamine salts, and suitable detergentsinclude (a) cationic detergents such as, for example, dimethyl dialkylammonium halides, and alkyl pyridinium halides; (b) anionic detergentssuch as, for example, alkyl, aryl, and olefin sulfonates, alkyl, olefin,ether, and monoglyceride sulfates, and sulfosuccinates, (c) nonionicdetergents such as, for example, fatty amine oxides, fatty acidalkanolamides, and polyoxyethylenepolypropylene copolymers, (d)amphoteric detergents such as, for example,alkyl-.beta.-aminopropionates, and 2-alkyl-imidazoline quaternaryammonium salts, and (e) mixtures thereof.

The parenteral formulations typically will contain from about 0.5 toabout 25% by weight of the active ingredient in solution. Preservativesand buffers may be used. In order to minimize or eliminate irritation atthe site of injection, such compositions may contain one or morenonionic surfactants having a hydrophile-lipophile balance (HLB) of fromabout 12 to about 17. The quantity of surfactant in such formulationswill typically range from about 5 to about 15% by weight. Suitablesurfactants include polyethylene sorbitan fatty acid esters, such assorbitan monooleate and the high molecular weight adducts of ethyleneoxide with a hydrophobic base, formed by the condensation of propyleneoxide with propylene glycol. The parenteral formulations can bepresented in unit-dose or multi-dose sealed containers, such as ampulesand vials, and can be stored in a freeze-dried (lyophilized) conditionrequiring only the addition of the sterile liquid excipient, forexample, water, for injections, immediately prior to use. Extemporaneousinjection solutions and suspensions can be prepared from sterilepowders, granules, and tablets of the kind previously described.

The sympathicomimetic agonist and/or beta blocker and/or potassium maybe formulated so it can be stored at room temperature in preformed bagsor syringes containing the solution with the sympathicomimetic agonistand/or beta blocker and/or potassium. The bag may be compartmentalizedenabling an initial loading dose of the beta blocker before infusion ofthe sympathicomimetic agonist and/or potassium commence. Likewise, thesyringe may be for single or dual injections and optionally allowingpremixing of sympathicomimetic agonist and beta blocker. Theconcentration of the sympathicomimetic agonist and beta blocker ispredefined enabling immediate dosing based on the patients weightregardless of age and gender. The preformed bag may be a 1 liter or a500 ml or any other conventionally sized bag formulated to toleratelight and be stable at room temperature. The syringe may be a 50 mlsyringe, or a syringe of any conventional size such as between 10 ml and100 ml.

The pharmaceutical composition may also be formulated in other formse.g. as a gel, liquid, or as compressed solid. The preferred form willdepend upon the particular indication being treated and will be apparentto one skilled in the art.

The compositions may contain pharmaceutically acceptable auxiliarysubstances as required to approximate physiological conditions, such aspH adjusting and buffering agents, stabilizing agents, preservatives,non-ionic surfactants or detergents, antioxidants, tonicity adjustingagents and the like, for example, sodium acetate, sodium lactate, sodiumchloride, potassium chloride, calcium chloride, etc.

The sympathicomimetic agonists may also be in a salt form thereof.Suitable salts include, but are not limited to, salts with alkali metalsor earth metals, such as sodium, potassium, calcium and magnesium aswell as e.g. zinc salts. These salts or complexes may be present as acrystalline and/or amorphous structure.

Administration of the sympathicomimetic agonists for the treatment ofbleeding episodes may either be the sole treatment or in any combinationwith other therapeutic agents such as red blood cells, and/or plasmaand/or platelets and/or other procoagulants such as any of thecoagulation factors alone or in combination and/or antifibrinolyticssuch as aprotinin, tranexamic acid amino caproic acid, and orvasocontrictors.

These agents may be incorporated as part of the same pharmaceuticalcomposition or may be administered separately from the sympathicomimeticagonists, either concurrently or in accordance with another treatmentschedule.

The sympathicomimetic agonists are primarily intended for parenteraladministration for prophylactic and/or therapeutic treatment.Preferably, the sympathicomimetic agonists are administeredparenterally, i.e., intravenously, subcutaneously, or intramuscularly,sublingual, mucosaaplication, intrapulmonary and it may be administeredby continuous or pulsatile infusion. The sympathcomimetic agonists canbe administered separately or in any combination both for therapeutic orprophylactic use.

In another aspect of the present invention, it has been found that clotstrength is better correlated with postoperative coagulopathic bleedingin subjects than conventional coagulation analysis including prothrombintime (PT), activated partial thromboplastin time (APTT), platelet countand fibrinogen levels undergoing cardiac surgery (Welsby et al. 2006).The clot strength can be approached by use of e.g. thrombelastography(TEG), as will be explained in details in the examples herein. Adheringto a transfusion algorithm aiming at a normal TEG clot strength reducesbleeding and postoperative transfusion requirements in cardiac surgery,liver transplantation and in critically ill patients as shown byShore-Lesserson et al. (1999), Kang (1995) and Johansson et al. (2007).

The compounds of the present invention may be formulated in a widevariety of oral administration dosage forms. The pharmaceuticalcompositions and dosage forms may comprise the compounds of theinvention or its pharmaceutically acceptable salt or a crystal formthereof as the active component. The pharmaceutically acceptablecarriers can be either solid or liquid. Solid form preparations includepowders, tablets, pills, capsules, cachets, suppositories, anddispersible granules. A solid carrier can be one or more substanceswhich may also act as diluents, flavoring agents, solubilizers,lubricants, suspending agents, binders, preservatives, wetting agents,tablet disintegrating agents, or an encapsulating material.

Preferably, the composition will be about 0.5% to 75% by weight of acompound or compounds of the invention, with the remainder consisting ofsuitable pharmaceutical excipients. For oral administration, suchexcipients include pharmaceutical grades of mannitol, lactose, starch,magnesium stearate, sodium saccharine, talcum, cellulose, glucose,gelatin, sucrose, magnesium carbonate, and the like.

In powders, the carrier is a finely divided solid which is a mixturewith the finely divided active component. In tablets, the activecomponent is mixed with the carrier having the necessary bindingcapacity in suitable proportions and compacted in the shape and sizedesired. The powders and tablets preferably containing from one to aboutseventy percent of the active compound(s). Suitable carriers aremagnesium carbonate, magnesium stearate, talc, sugar, lactose, pectin,dextrin, starch, gelatin, tragacanth, methylcellulose, sodiumcarboxymethylcellulose, a low melting wax, cocoa butter, and the like.The term “preparation” is intended to include the formulation of theactive compound(s) with encapsulating material as carrier providing acapsule in which the active component, with or without carriers, issurrounded by a carrier, which is in association with it. Similarly,cachets and lozenges are included. Tablets, powders, capsules, pills,cachets, and lozenges can be as solid forms suitable for oraladministration.

Examples of a Typical Tablet

A typical tablet which may be prepared by conventional tablettingtechniques may contain:

Core:

Sympathicomimetic agonist (as free compound or salt thereof) 100 mg Colloidal silicon dioxide (Aerosil) 1.5 mg Cellulose, microcryst.(Avicel)  70 mg Modified cellulose gum (Ac-Di-Sol) 7.5 mg Magnesiumstearate

Coating:

HPMC approx.   9 mg *Mywacett 9-40 T approx. 0.9 mg *Acylatedmonoglyceride used as plasticizer for film coating.

Optionally a beta blocker and/or potassium may also be included in theformulation.

Drops according to the present invention may comprise sterile ornon-sterile aqueous or oil solutions or suspensions, and may be preparedby dissolving the active ingredient in a suitable aqueous solution,optionally including a bactericidal and/or fungicidal agent and/or anyother suitable preservative, and optionally including a surface activeagent. The resulting solution may then be clarified by filtration,transferred to a suitable container which is then sealed and sterilizedby autoclaving or maintaining at 98-100.degree C for half an hour.Alternatively, the solution may be sterilized by filtration andtransferred to the container aseptically. Examples of bactericidal andfungicidal agents suitable for inclusion in the drops are phenylmercuricnitrate or acetate (0.002%), benzalkonium chloride (0.01%) andchlorhexidine acetate (0.01%). Suitable solvents for the preparation ofan oily solution include glycerol, diluted alcohol and propylene glycol.

Also included are solid form preparations which are intended to beconverted, shortly before use, to liquid form preparations for oraladministration. Such liquid forms include solutions, suspensions, andemulsions. These preparations may contain, in addition to the activecomponent, colorants, flavors, stabilizers, buffers, artificial andnatural sweeteners, dispersants, thickeners, solubilizing agents, andthe like.

Other forms suitable for oral administration include liquid formpreparations including emulsions, syrups, elixirs, aqueous solutions,aqueous suspensions, toothpaste, gel dentrifrice, chewing gum, or solidform preparations which are intended to be converted shortly before useto liquid form preparations. Emulsions may be prepared in solutions inaqueous propylene glycol solutions or may contain emulsifying agentssuch as lecithin, sorbitan monooleate, or acacia. Aqueous solutions canbe prepared by dissolving the active component in water and addingsuitable colorants, flavors, stabilizing and thickening agents. Aqueoussuspensions can be prepared by dispersing the finely divided activecomponent in water with viscous material, such as natural or syntheticgums, resins, methylcellulose, sodium carboxymethylcellulose, and otherwell known suspending agents. Solid form preparations include solutions,suspensions, and emulsions, and may contain, in addition to the activecomponent, colorants, flavors, stabilizers, buffers, artificial andnatural sweeteners, dispersants, thickeners, solubilizing agents, andthe like.

The compounds of the present invention may be formulated for aerosoladministration, particularly to the respiratory tract and includingintranasal administration. The compound will generally have a smallparticle size for example of the order of 5 microns or less. Such aparticle size may be obtained by means known in the art, for example bymicronization. The active ingredient is provided in a pressurized packwith a suitable propellant such as a chlorofluorocarbon (CFC) forexample dichlorodifluoromethane, trichlorofluoromethane, ordichlorotetrafluoroethane, carbon dioxide or other suitable gas. Theaerosol may conveniently also contain a surfactant such as lecithin. Thedose of drug may be controlled by a metered valve. Alternatively theactive ingredients may be provided in a form of a dry powder, forexample a powder mix of the compound in a suitable powder base such aslactose, starch, starch derivatives such as hydroxypropylmethylcellulose and polyvinylpyrrolidine (PVP). The powder carrier will form agel in the nasal cavity. The powder composition may be presented in unitdose form for example in capsules or cartridges of e.g., gelatin orblister packs from which the powder may be administered by means of aninhaler.

When desired, formulations can be prepared with enteric coatings adaptedfor sustained or controlled release administration of the activeingredient.

The pharmaceutical preparations are preferably in unit dosage forms. Insuch form, the preparation is subdivided into unit doses containingappropriate quantities of the active component. The unit dosage form canbe a packaged preparation, the package containing discrete quantities ofpreparation, such as packeted tablets, capsules, and powders in vials orampoules. Also, the unit dosage form can be a capsule, tablet, cachet,or lozenge itself, or it can be the appropriate number of any of thesein packaged form.

The Pharmaceutical Carrier

Illustrative solid carriers include lactose, terra alba, sucrose, talc,gelatin, agar, pectin, acacia, magnesium stearate, stearic acid and thelike. A solid carrier can include one or more substances which may alsoact as flavoring agents, lubricants, solubilizers, suspending agents,fillers, glidants, compression aids, binders or tablet-disintegratingagents; it can also be an encapsulating material. In powders, thecarrier is a finely divided solid which is in admixture with the finelydivided active ingredient. In tablets, the active ingredient is mixedwith a carrier having the necessary compression properties in suitableproportions, and compacted in the shape and size desired. The powdersand tablets preferably contain up to 99% of the active ingredient.Suitable solid carriers include, for example, calcium phosphate,magnesium stearate, talc, sugars, lactose, dextrin, starch, gelatin,cellulose, methyl cellulose, sodium carboxymethyl cellulose,polyvinylpyrrolidine, low melting waxes and ion exchange resins.

Illustrative liquid carriers include syrup, peanut oil, olive oil,water, etc. Liquid carriers are used in preparing solutions,suspensions, emulsions, syrups, elixirs and pressurized compositions.The active ingredient can be dissolved or suspended in apharmaceutically acceptable liquid carrier such as water, an organicsolvent, a mixture of both or pharmaceutically acceptable oils or fats.The liquid carrier can contain other suitable pharmaceutical additivessuch as solubilizers, emulsifiers, buffers, preservatives, sweeteners,flavoring agents, suspending agents, thickening agents, colors,viscosity regulators, stabilizers or osmo-regulators. Suitable examplesof liquid carriers for oral and parenteral administration include water(partially containing additives as above, e.g. cellulose derivatives,preferably sodium carboxymethyl cellulose solution), alcohols (includingmonohydric alcohols and polyhydric alcohols, e.g. glycols) and theirderivatives, and oils (e.g. fractionated coconut oil and arachis oil).For parenteral administration, the carrier can also be an oily estersuch as ethyl oleate and isopropyl myristate. Sterile liquid carders areuseful in sterile liquid form compositions for parenteraladministration. The liquid carrier for pressurized compositions can behalogenated hydrocarbon or other pharmaceutically acceptable propellant.Liquid pharmaceutical compositions which are sterile solutions orsuspensions can be utilized by, for example, intramuscular,intraperitoneal or subcutaneous injection. Sterile solutions can also beadministered intravenously. The compound can also be administered orallyeither in liquid or solid composition form.

Several scenarios can be envisaged where administration of asympathicomimetic agonist and/or a beta blocker and/or potassium wouldbe of benefit to a bleeding subject. One is in the hospital/clinic orother similarly well supervised conditions where the subject either willbe undergoing planned surgery or is admitted in a state that requiressurgery. In such instances an embodiment of the present inventioncomprising a sympathicomimetic agonist and/or a beta blocker and/orpotassium in a pre-prepared and ready to use solution such as in aninfusion bag or pre-prepared syringe will be preferable. Thepre-prepared solution may then be administered prior to, during or aftersurgery.

A specially preferred embodiment of this aspect of the present inventioncomprises a pre-prepared formulation of a sympathicomimetic agonist anda beta blocker and/or potassium that may be stored at ambienttemperature, i.e. room temperature, and which also is unaltered (i.e.the compounds do not degrade/breakdown become metabolized or otherwiseloose their activity) if exposed to light. Furthermore it is preferredif the formulation is such that it may be administered in the correctdosage immediately, for example at a dosage of 3 microgram/kg/hour.

Another scenario is following a situation of emergency such as a trafficaccident, military exercise or warfare where the bleeding subject willbenefit from immediate staunching of the bleeding. In this scenario, apre-prepared formulation may be of a sympathicomimetic agonist and/or abeta blocker and/or potassium, preferably just a sympathicomimeticagonist in a form that allows immediate administration i.e. in apre-prepared syringe (for i.e. intra muscular, intravenous orsubcutaneous administration) or tablet or other mucosal applicationform. This formulation may be administered to the subject at the scene,in an ambulance or helicopter.

An embodiment of the invention thus relates to a pre-prepared syringewith a content befitting the average adult or child human being. Theaverage adult human being may thus way 70 kg and therefore thepre-prepared syringe may have a content of between 210 and 3150microgram adrenaline is a suitable volume. The average adult or childhuman weight after which the amount of sympathicomimetic agonist iscalculated may be adapted to suit specific circumstances such aschildren of different age groups (they are expected to increase inweight with age) or different nationalities, as different nations havedifferent mean weights of their inhabitants. The same amount ofadrenaline or noradrenaline or any sympathicomimetic may correspondinglybe pressed into a tablet. Likewise, a pre-prepared syringe may be madefor the specific purpose of having a duration of 5 min, 10 min, 15 min,30 min, or 60 min or anything therein between.

Embodiments of Use

The sympathicomimetic agonists and/or beta blockers and/or potassiumcombinations are particular suitable for the treatment and/orprophylaxis of bleeding, including uncontrolled and excessive bleedingepisodes in connection with surgery and other forms of tissue damage. Inthe following is provided a non-exhaustive description of variousconditions were sympathicomimetic agonists and/or beta blockers and/orpotassium combinations, either administered alone or in combination withany of the above mentioned treatments, are envisaged to be beneficial incontrolling or preventing bleedings, due to their above-describedsystemic hemostatic properties.

Treatment of Bleeding Caused by Trauma

In subjects who experience extensive tissue damage in association withsurgery or vast trauma, the normal hemostatic mechanism may beoverwhelmed by the demand of immediate hemostasis and they may developbleeding in spite of a normal hemostatic mechanism. It is envisaged thatin any form of trauma, systemic administration of sympathicomimeticagonists may be beneficial to the subject.

As used herein, the term “trauma” is intended to mean injury to livingtissue caused by an extrinsic agent.

Hemorrhage as a result of trauma can start a cascade of problems. Forexample physiological compensation mechanisms are initiated with theinitial peripheral mesenteric vasoconstriction to shunt blood to thecentral circulation. If circulation is not restored, hypovolaemic shockensures (multiple organ failure due to inadequate perfusion.) Traumapatients may develop hypothermia due to environmental conditions at thescene, inadequate protection, intravenous fluid and blood productadministration and ongoing blood loss. Deficiencies in coagulationfactors and platelets can result from blood loss, dilution, consumptionor transfusions. Meanwhile acidosis and hypothermia interfere withnormal blood clotting mechanisms. Thus coagulophathy develops which maymask surgical bleeding sites and hamper control of mechanical bleeding.Hypothermia, coagulophathy and acidosis are often characterized as the“lethal triad” as these conditions often lead to uncontrollable bloodloss, multiple organ failure and death typically in an intensive careunit.

In addition to hypovolaemic shock as a result of blood loss, shock mayalso develop as a result of activation of the inflammatory pathways,resulting in a hypocoagulant state. This subset of trauma patients hasparticularly high mortality.

One general aspect of the invention therefore relates to methods oftreatment of bleeding in patients suffering from various forms oftrauma.

In one embodiment, the invention thus relates to a method for thetreatment of bleeding caused by trauma in a subject, comprisingadministering to said subject a sympathicomimetic agonist and/or a betablocker and/or potassium.

In one embodiment, the invention thus relates to a method for thetreatment of bleeding caused by trauma towards the head and/or neckincluding but not limited to the brain, eye(s), ear(s), nose, mouth,esophagus, trachea, soft tissues, muscles, bones and/or vessel(s) in asubject, comprising administering to said subject a sympathicomimeticagonist and/or a beta blocker and/or potassium.

In one embodiment, the invention thus relates to a method for thetreatment of bleeding caused by trauma towards the thoracic regionincluding but not limited to the heart, lungs, oesophagus, soft tissues,muscles or any vessel or vessels in a subject, comprising administeringto said subject a sympathicomimetic agonist and/or a beta blocker and/orpotassium.

In one embodiment, the invention thus relates to a method for thetreatment of bleeding caused by trauma towards the abdomen including butnot limited to the liver, pancreas, spleen, ventricle, gall-bladder,intestines, or retroperitoneal tissue, soft tissues, muscles or anyvessel or vessels in a subject, comprising administering to said subjecta sympathicomimetic agonist and/or a beta blocker and/or potassium.

In one embodiment, the invention thus relates to a method for thetreatment of bleeding caused by trauma towards the pelvis including butnot limited to prostate, urinary bladder, uterus, ovarii, bones i.e.pelvic ring, hip, femur, soft tissues, muscles or any vessel or vesselsin a subject, comprising administering to said subject asympathicomimetic agonist and/or a beta blocker and/or potassium.

In one embodiment, the invention thus relates to a method for thetreatment of bleeding caused by trauma towards the long bones of theextremities including but not limited to humerus, ulnae, radii and/orbones of the hand, femur, tibia, fibula and/or bones of the foot, thecolumnae, scapulae, costae, clavicle or in any combination hereof in asubject, comprising administering to said subject a sympathicomimeticagonist and/or a beta blocker and/or potassium.

In one embodiment, the invention thus relates to a method for thetreatment of bleeding caused by trauma towards any combination of theabove in a subject, comprising administering to said subject asympathicomimetic agonist and/or a beta blocker and/or potassium.

In another embodiment, the invention relates to a method for thetreatment of subjects suffering from shock as a result of blood lossafter trauma comprising administering to said subject asympathicomimetic agonist and/or a beta blocker and/or potassium.

In an additional embodiment, the invention relates to use ofsympathicomimetic agonists and/or beta blockers and/or potassium for thepreparation of a medicament for treatment of bleeding in connection withany of the indications discussed above.

Treatment of Bleedings in the Brain and Central Nervous System

Intracerebral hemorrhage (ICH) is the most deadly form of stroke. Inaddition to high short-term mortality rates, ICH also results in veryhigh rates of severe mental and physical disability among survivors. Thecauses of ICH are numerous and can include head trauma, traumatic braininjury (TBI), hypertensive hemorrhage, transformation of prior ischemicinfarction (ischemic stroke), metastatic brain tumor, coagulophathy,drug induced ICH, arteriovenous malformation, aneurysm, amyloidangiopathy, cavernous angioma, dural arteriosvenous fistula andcapillary telaniectasias.

A further embodiment of this aspect of the invention relates to methodsfor the treatment of primary intracerebral bleeding (ICH) in a subject,comprising administering to said subject a sympathicomimetic agonistand/or a beta blacker and/or potassium.

In an additional embodiment, the invention relates to use ofsympathicomimetic agonists and/or beta blockers and/or potassium for thepreparation of a medicament for treatment of bleeding in connection withany of the ICH-related causes of a subject as discussed above.

Treatments of Surgical Bleeds

Another situation is when subjects are to undergo elective or acutesurgical interventions where bleeding may occur and hence whereadministration of blood products may become necessary. The surgery maybe either a scheduled or acute procedure, and may be any type of surgeryon any part of the body.

One embodiment of this aspect of the invention thus relates to methodsfor the treatment of a subject in connection with surgical inventions,comprising administering to said subject a sympathico mimetic agonistand/or a beta blocker and/or potassium.

Additionally, the invention relates to use of sympathicomimetic agonistsand/or beta blockers and/or potassium for the preparation of amedicament for the treatment of bleeding in connection with surgery asdiscussed above.

One general aspect of the invention therefore relates to methods oftreatment of bleeding in patients suffering from/undergoing variousforms of surgery.

In one embodiment, the invention thus relates to a method for thetreatment of bleeding caused by surgery in a subject, comprisingadministering to said subject a sympathicomimetic agonist and/or a betablocker and/or potassium.

In one embodiment, the invention thus relates to a method for thetreatment of bleeding caused by surgery in the head and/or neckincluding but not limited to the brain, eye(s), ear(s), nose, mouth,esophagus, trachea, bones, soft tissue, muscles and vessel(s) in asubject, comprising administering to said subject a sympathicomimeticagonist and/or a beta blocker and/or potassium.

In one embodiment, the invention thus relates to a method for thetreatment of bleeding caused by surgery in the thoracic region includingbut not limited to the heart, lungs, oesophagus, soft tissue, muscles orany vessel or vessels in a subject, comprising administering to saidsubject a sympathicomimetic agonist and/or a beta blocker and/orpotassium.

In one embodiment, the invention thus relates to a method for thetreatment of bleeding caused by surgery in the abdomen including but notlimited to the liver, pancreas, spleen, kidney, adrenal glands,ventricle, gall-bladder, intestines, retroperitoneal tissue, softtissue, muscles or any vessel or vessels in a subject, comprisingadministering to said subject a sympathicomimetic agonist and/or a betablocker and/or potassium.

In one embodiment, the invention thus relates to a method for thetreatment of bleeding caused by surgery in the pelvis including but notlimited to prostate, urinary bladder, uterus, ovarii, bones i.e. pelvicring, hip, femur, soft tissue, muscles or any vessel or vessels in asubject, comprising administering to said subject a sympathicomimeticagonist and/or a beta blocker and/or potassium.

In one embodiment, the invention thus relates to a method for thetreatment of bleeding caused by surgery of the long bones of theextremities including but not limited to humerus, ulnae, radii and/orbones of the hand, femur, tibia, fibula and/or bones of the foot, thecolumnae, scapulae, costae, clavicle, soft tissue, muscles or in anycombination hereof in a subject, comprising administering to saidsubject a sympathicomimetic agonist and/or a beta blocker and/orpotassium.

In one embodiment, the invention this relates to a method for thetreatment of bleeding caused by surgery in any combination of the abovein a subject, comprising administering to said subject asympathicomimetic agonist and/or a beta blocker and/or potassium.

Additionally, the invention relates to use of sympathicomimetic agonistsand/or beta blockers and/or potassium for the preparation of amedicament for the treatment of bleeding in connection with surgery asdiscussed above.

Treatment of Bleedings Associated with Vascular Defects

Bleeding secondary to vascular defects may arise due to congenital oracquired defects of the vascular system resulting in aneurysms ofarteries and or veins, arterioveinuous malformations or rupture ofatherosclerotic plaques. These bleedings may be severe orlife-threatening depending on localization i.e. intracerebral and/or thesize of vessel(s) affected, exemplified by ruptured aortic lesions.

One embodiment of this aspect of the invention thus relates to methodsfor the treatment of a subject in connection with vascular defects,comprising administering to said subject a sympathicomimetic agonistand/or a beta blocker and/or potassium.

Additionally, the invention relates to use of sympathicomimetic agonistsand/or beta blockers and/or potassium for the preparation of amedicament for the treatment of bleeding in connection with vasculardefects as discussed above.

One general aspect of the invention therefore relates to methods oftreatment of bleeding in patients suffering from various forms ofvascular defects.]

In one embodiment, the invention thus relates to a method for thetreatment of bleeding caused by vascular defects in a subject,comprising administering to said subject a sympathicomimetic agonistand/or a beta blocker and/or potassium.

In one embodiment, the invention thus relates to a method for thetreatment of bleeding caused by vascular defects in the head and/or neckregion including, but not limited to the brain, eye(s), ear(s), nose,mouth, esophagus, trachea, soft tissue or muscles in a subject,comprising administering to said subject a sympathicomimetic agonistand/or a beta blocker and/or potassium.

In one embodiment, the invention thus relates to a method for thetreatment of bleeding caused by vascular defects in the thoracic regionincluding but not limited to the heart, lungs, esophagus, soft tissue ormuscles or any other vessel or vessels in a subject, comprisingadministering to said subject a sympathicomimetic agonist and/or a betablocker and/or potassium.

In one embodiment, the invention thus relates to a method for thetreatment of bleeding caused by vascular defects in the abdomenincluding but not limited to the liver, pancreas, spleen, kidney,adrenal glands, ventricle, gall-bladder, intestines, retroperitonealtissue, soft tissue or muscles or any other vessel or vessels in asubject, comprising administering to said subject a sympathicomimeticagonist and/or a beta blocker and/or potassium.

In one embodiment, the invention thus relates to a method for thetreatment of bleeding caused by vascular defects in the pelvis includingbut not limited to prostate, urinary bladder, uterus, ovarii, bones i.e.pelvic ring, hip, femur, soft tissue or muscles or any vessel or vesselsin a subject, comprising administering to said subject asympathicomimetic agonist and/or a beta blocker and/or potassium.

In one embodiment, the invention thus relates to a method for thetreatment of bleeding caused by vascular defects in the soft tissueand/or muscles surrounding of the long bones of the extremitiesincluding but not limited to humerus, ulnae, radii and/or bones of thehand, femur, tibia, fibula and/or bones of the foot, the columnae,scapulae, costae, clavicle, soft tissue or muscles or in any combinationhereof in a subject, comprising administering to said subject asympathicomimetic agonist and/or a beta blocker and/or potassium.

In one embodiment, the invention thus relates to a method for thetreatment of bleeding caused by vascular defects in any combination ofthe above in a subject, comprising administering to said subject asympathicomimetic agonist and/or a beta blocker and/or potassium.

Additionally, the invention relates to use of sympathicomimetic agonistsand/or beta blockers and/or potassium for the preparation of amedicament for the treatment of bleeding in connection with variousforms of vascular defects discussed above.

Treatment of Bleeding Associated with Biopsies and Laparoscopic Surgery

A further aspect of the invention relates to methods of treatment ofbleeding in subject undergoing biopsies from various organs (brain,heart, liver, lung, pancreas, spleen, lymphoid tissue, intestines,adrenal glands, tumors, soft tissue, muscles, gastrointestinal tract) aswell as in laparoscopic surgery.

In one embodiment, the invention thus relates to a method for thetreatment of bleeding in subjects undergoing biopsies, comprisingadministering to said subject a sympathicomimetic agonist and/or a betablocker and/or potassium.

In another embodiment, the invention relates to a method for thetreatment of bleeding in subjects undergoing laparoscopic surgery,comprising administering to said subject a sympathicomimetic agonistand/or a beta blocker and/or potassium.

In an additional embodiment, the invention relates to the use ofsympathicomimetic agonists and/or beta blockers and/or potassium for thepreparation of a medicament for treatment of bleeding as a in a subjectundergoing biopsies as discussed above or undergoing laparoscopicsurgery.

Treatment of Bleeding Caused by Coagulopathy

Uncontrolled and/or excessive bleeding may occur in subjects having anormal coagulation system and subjects having coagulation or bleedingdisorders. Excessive bleedings may also occur in subjects with anormally functioning blood clotting cascade (no clotting factordeficiencies or -inhibitors against any of the coagulation factors).

Bleeding secondary to coagulopathy i.e. coagulation factor dilution withcrystalloids and or colloids and/or blood products and/or consumptionsuch as but not limited to infection, sepsis, DIC (disseminatedintravascular coagulation), haematological disorders and malignancies,graft vs. host disease, and/or congenital or acquired coagulation factordeficiency such as but not limited to haemophilia A or B, inhibitorsagainst coagulation factors.

In one embodiment, the invention relates to a method for the treatmentof bleeding in a coagulopathic subject, comprising administering to saidsubject a sympathicomimetic agonist and/or a beta blocker and/orpotassium.

In an additional embodiment, the invention relates to use ofsympathicomimetic agonists and/or beta blockers and/or potassium for thepreparation of a medicament for treatment of bleeding in a coagulopathicsubject.

Treatment of Bleeding as a Consequence of Treatment withAnticoagulants/Antithrombotics

Bleeding, also acute and/or profuse may also occur in subjects onanticoagulant therapy in whom a defective hemostasis has been induced bythe therapy given. Such subjects may need surgical interventions in casethe anticoagulant effect has to be counteracted rapidly. Anothersituation that may cause problems in the case of unsatisfactoryhemostasis is when subjects with a normal hemostatic mechanism are givenanticoagulant therapy to prevent thromboembolic disease. Such therapymay include heparin both unfractionated and low molecular weight, otherforms of proteoglycans, activated protein C, antithrombin, tissue factorpathway inhibitor, warfarin or other forms of vitamin K-antagonists aswell as aspirin, dipyrimidol, NSAID, GPIIb/IIIa inhibitors, Flolan(prostacyclin) ADP receptor inhibitors, direct thrombin inhibitors,hirudin, citrate, and other platelet activation/aggregation inhibitors.A further general aspect of the invention therefore relates to methodsof treatment of bleeding in connection with anticoagulant therapy.

In one embodiment, the invention thus relates to a method for treatmentof bleeding in a subject receiving an anticoagulant and antithromboticdrug, comprising administering to said subject a sympathicomimeticagonist and/or a beta blocker and/or potassium.

In an additional embodiment, the invention relates to use ofsympathicomimetic agonists and/or beta blockers and/or potassium for thepreparation of a medicament for treatment of bleeding complication dueto anticoagulant treatment in a subject.

Treatment of Thrombocytopenic Subjects

Thrombocytopenic subjects are characterized by a reduced blood platelet(thrombocyte) count resulting from a reduced platelet production and/oran increased loss of platelets. There are numerous causes ofthrombocytopenia such as decreased bone marrow production ofmegakaryocytes (e.g. due to marrow infiltration with tumor or fibrosis,or marrow failure induced by e.g. aplasia, hypoplastic anemias, orchemotherapy or other drugs), splenic sequestration of circulatingplatelets (e.g. splenic enlargement due to tumor infiltration or pleniccongestion due to portal hypertension), increased destruction ofcirculating platelets (e.g. due to vascular prosthese, cardiac valves,disseminated intravascular coagulation (DIC), sepsis, vasculitis,autoantibodies to platelets, drug-associated antibodies, or circulatingimmune complexes induced by systemic lupus erythematosis, viral agents,bacterial sepsis or idiopathic thrombocytopenic pupora (ITP), plateletdisorders, von Willebrands disease, Bernhard-Soulier syndrome,Glanzmann's thrombasthenia, decreased cyclooxygenase activity (druginduced or congeniital), granule storage pool defects (acquired orcongenital), uremia, platelet coating (e.g. due to penicillin orparaproteins), defective platelet coagulant activity (Scott's syndrome,or thrombocytopenia associated with liver disease such as caused byhepatitis C or hepatitis B, or caused by IFN-alpha treatment ofhepatitis C or hepatitis B as well as secondary to hypersplenism

Another general aspect of the invention thus relates to treatment ofbleeding in connection with thrombocytopenia caused by e.g. any of theconditions discussed above.

In one embodiment, the invention thus relates to a method for treatmentof bleeding in connection with thrombocytopenia in a subject, comprisingadministering to said subject a sympathicomimetic agonist and/or a betablocker and/or potassium.

In an additional embodiment, the invention relates to use ofsympathicomimetic agonists and/or beta blockers and/or potassium for thepreparation of a medicament for treatment of bleeding in connection withthrombocytopenia caused by e.g. any of the conditions discussed above.

Another aspect of the invention relates to the treatment of bleeding ina subject caused by a combination of coagulopathy (coagulation factordeficiency) and thrombocytopenia (low platelet count) or due to lowplatelet function

In one embodiment, the invention thus relates to a method for treatmentof bleeding in connection with a combination of coagulopathy (acquiredor congenital) and thrombocytopenia (acquired or congenital) in asubject, comprising administering to said subject a sympathicomimeticagonist and/or a beta blacker and/or potassium.

In an additional embodiment, the invention relates to the use ofsympathicomimetic agonists for the preparation of a medicament fortreatment of bleeding in connection with coagulopathy (acquired orcongenital) and thrombocytopenia (acquired or congenital) caused by e.g.any of the conditions discussed above.

Treatment of Bleedings Associated with Transplantation

Patients undergoing transplantation of solid organs, such as but notlimited to liver, heart, lungs, pancreas, kidneys and/or intestines areat high risk of developing bleeding due to the surgically inducedbleeding. Also patients undergoing hematopoietic stem cell or bonemarrow transplantation are at risk of bleeding due to the conditioningof the patients with body irradiation and chemotherapy eradicating thepatients hematopoietic system and hence severely deficient of plateletsand red blood cells. In the post-transplant period these patients are atrisk of developing graft vs. host disease, which may result in bleedingsfrom the liver, gastrointestinal and urogenital system as well as fromthe bronchioalveolar system.

In one embodiment, the invention thus relates to a method for treatmentof bleeding in connection with solid organ or hematopoietic systemtransplantation in a subject, comprising administering to said subject asympathicomimetic agonist and/or a beta blacker and/or potassium.

In an additional embodiment, the invention relates to use ofsympathicomimetic agonists and/or beta blockers and/or potassium for thepreparation of a medicament for treatment of bleeding in connection withsolid organ or hematopoietic system transplantation caused by e.g. anyof the conditions discussed above.

DETAILED DESCRIPTION OF THE DRAWINGS

FIG. 1: TEG technology. See Example 1 for explanation.

FIG. 2: TEG parameters. The following parameters are derived from a TEGtracing; R, the time from start of analysis until initial clot formation(at 2 mm amplitude); Angle, representing velocity of clot formation; MA,maximal amplitude, the maximal physical clot strength; Lysis AUC, thearea under the fibrinolysis curve calculated from MA (hatched area).

FIG. 3: Representative TEG profile of healthy volunteers before andafter administration of adrenaline. Whole blood was drawn in 1/10citrate from an arterial catheter. The citrated whole blood samplerested exactly 30 minutes at room temperature before TEG analysis on theThrombelastograph Hemostasis Analyser, series 5000 (Haemoscope Corp.,Skokie, Ill.): One ml of citrated whole blood was transferred to akaolin vial (Haemoscope Corp.) and gently mixed by inversion 5 times.From the kaolin vial 340 μl was added to a plain TEG cup preloaded with20 μl of 0.2 M CaCl₂ and the analysis started immediately.

FIG. 4: TEG parameters (a) R, (b) Angle and (c) MA of 30 healthyvolunteers after totally 15 minutes of i.v. administration ofadrenaline. The subjects were catheterized and rested 60 minutes beforeadministration of adrenaline was commenced. Adrenaline was step-wiseinfused intravenously for 5 minutes at each of the doses 3.5 μg/kg/h,5.0 μg/kg/h and 6.0 μg/kg/h. Blood samples were collected from anarterial catheter at baseline (t=0) and immediately after each dose(t=5, t=10 and t=15). Results are presented as mean with 95% confidenceinterval (CI) and analyzed by 1-way ANOVA (Friedman), followed by posthoc Dunn's Multiple Comparison Test, t=0 vs t=5, t=10 and t=15respectively, *p<0.05, ***p<0.001.

FIG. 5: TEG MA measured before and after i.v. infusion of noradrenalineat 4.8 μg/kg/h for 15 minutes in 10 healthy volunteers, mean with 95%CI. MA before and after noradrenaline was compared by a paired t-testwith a p-value <0.05 considered statistically significant.

FIG. 6: TEG MA measured before (t=0) and after i.v. infusion ofadrenaline at 4.8 1 μg/kg/h for 15 minutes (t=15) and 30 minutes afterdiscontinuation of adrenaline administration (t=45). Data presented asmean with 95% CI. Friedman 1-way ANOVA and Bonferroni post hoc test wasused for comparing t=0 to t=15 and to t=45, respectively, **p<0.01, ns;non-significant.

FIG. 7: TEG parameters (a) R, (b) Angle and (c) MA measured as describedin FIG. 3 and example 1 on blood samples collected from patients infusedwith adrenaline prior to prostatectomy. Ten patients were anesthetizedby propofol and haldid and infused with adrenaline i.v. in the doses 1,2 and 3 μg/kg/h each for 5 minutes prior to skin incision. Hereafter thepatients were prostatectomised according to local protocol. Bloodsamples were collected from an arterial catheter before adrenalineadministration and immediately after each infusion dose (1, 2 and 3μg/kg/h) and again 1 hour after discontinuation of adrenaline infusion.Statistics used: One-way ANOVA, Friedman Test, and Dunn's MultipleComparison post hoc test of “before” compared to each of the followingpoints 1, 2, 3 μg/kg/h and 1 hour after termination of adrenalineinfusion, *p<0.05, **p<0.01,***p<0.001, ns: non-significant.

FIG. 8: Perioperative bleeding (in ml) of the 10 patients described inFIG. 7 (receiving adrenaline in the step-wise doses 1, 2 and 3 μg/kg/h)and 10 other prostatectomy patients receiving a 15 minutes continuousadrenaline infusion of 3 μg/kg/h. The 2 intervention groups werecompared to 40 controls also undergoing prostatectomy, whereof 20underwent surgery prior to the interventions and the last 20 after theintervention. All values including median for each group is depicted.Comparisons between control group and each of the intervention groupswas done separately by Mann Whitney test.

FIG. 9: Healthy volunteers received adrenaline as described in FIG. 4.Arterial blood was collected in citrate before and after the lastadrenaline dose (t=15) and again 30 minutes after end of infusion(t=45). The blood was analyzed with TEG (described in FIG. 3) afteraddition of tissue plasminogen activator (tPA) in a final concentrationof 2.4 nM. (a) A representative example of TEG tracings with tPA inducedfibrinolysis before and immediately after infusions of adrenaline. (b)Comparisons of the lysis AUC values t=0 vs. t=15 and t=10 vs. t=45,respectively by 1-way ANOVA, Friedman test and post hoc Dunn's MultipleComparison Test, **p<0.01, ns: not significant.

FIG. 10: Seven healthy volunteers received 3 doses of adrenalineinfusion lasting for 5 minutes each in the following step-wiseincreasing doses 3.5, 5.0 and 6.0 μg/kg/h. After resting 1 hour, thesubjects received 0.15 μg/kg Seloken i.v. and rested again 30 minutesbefore repeating the step-wise adrenaline infusions. Blood samples wereobtained from an arterial catheter at baseline (t=0.0), after each ofthe first adrenaline doses (t=5.0, t=10.1, t=15.0), at baseline afterSeloken administration and rest (t=0.1) and after each of the subsequentadrenaline infusions (t=5.1, t=10.1, t=15.1). The blood was analyzedwith TEG as described in FIG. 3 and Example 1. TEG MA values arepresented as mean with 95% CI and analyzed with a 2-way repeatedmeasurements (RM) ANOVA with post hoc Bonferroni adjusted paired t-testof t=0.0 vs. t=5.0, t=10.1, t=15.0, respectively and t=0.1 vs. t=5.1,t=10.1, t=15.1, ***p<0.001.

FIG. 11: The healthy subjects described in FIG. 10 were monitoredhaemodynamically at the same time points as described in FIG. 10. (a)heart rate (HR), (b) cardiac output (CO), (c) stroke volume (SV), (d)invasive blood pressure: mean arterial pressure, MAP) and (d) totalperipheral resistance (TPR). All results are presented as mean with 95%CI and analyzed with 2-way repeated measurements ANOVA (RM ANOVA)followed by post hoc Bonferroni adjusted paired t-tests comparingbaseline to each of the adrenaline concentrations for both treatments(without or with Seloken pre-treatment, respectively). P-values foradrenaline concentration, treatment and conc x treatment effects in therepeated measures model are shown. The conc x treatment is an analysisof the total response/the total pattern, to check whether there is aninteraction between concentration and treatment. If the only significanteffect was concentration, the post hoc Bonferroni results in respect ofsignificance level are shown (a,c,d). If the effect of conc x treatmentwas significant (p<0.05), a Friedman 1-way ANOVA was performed for eachtreatment, followed by a Bonferroni-adjusted paired t-test comparingadrenaline concentrations separately (b). If concentration and treatmenteffect were significant without a significant conc x treatment effectseparate Bonferroni-adjusted paired t-tests were performed directly (e).*p<0.05, **p<0.01, ***p<0.001, ns: non significant. ANOVA: Analysis ofvariance.

FIG. 12: Three healthy volunteers received 5 doses of adrenalineinfusion lasting for 5 minutes each in the following step-wiseincreasing doses 1, 3, 5, 7, and 9 μg/kg/h. After resting 1 hour, thesubjects received Seloken i.v. 0.20 μg/kg for 10 minutes and restedagain 30 minutes before repeating the step-wise adrenaline infusions.Blood samples were obtained from an arterial catheter at baseline (0.0μg/kg/h)), after each of the first adrenaline doses, at baseline afterSeloken administration and rest and after each of the subsequentadrenaline infusions. The blood was analyzed with TEG as described inFIG. 3 and Example 1. TEG MA values are presented as mean with 95% CI.

EXAMPLES Example 1 Thrombelastography (TEG)

The TEG in vitro assay is suitable for determining important parametersin the hemostatic process including clot strength. The TEG system'sapproach to monitoring patient hemostasis is based on the premise thatthe end result of the hemostatic process is the clot. The clot'sphysical properties determine whether the patient will have normalhemostasis, or will be at increased risk for haemorrhage or thrombosis[Salooja et al. 2001].

The TEG analyzer uses a small whole blood sample in a rotating cup and apin suspended in the blood by a torsion wire, which is monitored formotion. The torque of the rotating cup is transmitted to the immersedpin only after fibrin and/or fibrin-platelet bonding has linked the cupand pin together (FIG. 1). The strength and rate of these bonds affectthe magnitude of the pin motion such that strong clots move the pin morethan less strong clots. Thus, the TEG technology documents theinteraction of platelets with the protein coagulation cascade from thetime of placing the blood in the analyzer until initial fibrinformation, clot rate strengthening and fibrin-platelet bonding viaGPIIb/IIIa, through eventual clot lysis (FIG. 2). The TEG R parameterreflects the initiation phase, reaction time, from start of coagulationuntil the first fibrin band is formed; the Angle (a) represents theincrease in clot strength, clot kinetics, correlating with the thrombingeneration. The maximal amplitude (MA) parameter reflects maximal clotstrength i.e. the maximal elastic modus of the clot. The area under thelysis curve, i.e. area under curve from MA is obtained (Lysis AUC)reflects degree of fibrinolyis.

The TEG system has been recognized as a uniquely useful tool and hasbeen used extensively in the management of bleeding during majorsurgical interventions such as liver transplantations [Kang Y. 1995] andcardiovascular procedures [Shore-Lesserson et al. 1999] as well asobstetrics, trauma, neurosurgery, management of deep vein thrombosis,and the monitoring and differentiation among platelet GPIIb/IIIaantagonists [Di Benedetto 2003]. TEG-guided transfusion therapy aimingat normalizing clot strength (MA) has resulted in a reduction in the useof blood products, a reduction in the rate of re-exploration, predictionof bleeding in cardiac surgery and it is approved by the FDA for themonitoring of patients with heart assist devices. The clinical utilityof the TEG rely in its reflection of thrombin generation and theresulting physical properties of the clot [Rivard et al. 2005].

A whole blood sample for TEG analysis was drawn into a tube containingcitrate (9 volumes of blood into 1 volume of 0.129 M citrate; VACUTAINERsystem, BD Biosciences, Plymouth, UK) and rested for exactly 30 minutesbefore analysis: Coagulation was initiated by kaolin and re-calcifiedaccording to the instructions of the manufacturer: Citrated whole bloodwas added to a kaolin vial and mixed by gently inversion 5 times beforetransfer to the TEG cup containing calcium chloride (20 μl of 0.2 MCaCl₂), which was preloaded into the TEG′ cup as published previously[Johansson et al. 2008]. The hemostatic process was recorded by use of aTEG® coagulation analyzer (5000 series, Haemoscope Corporation).Adrenaline was mixed with 0.9% NaCl and infused intravenously.

FIG. 3 illustrates TEG profiles from a representative volunteer beforeand after receiving intravenous infusion of adrenaline 3 μg/kg/h for 15minutes. As illustrated in FIG. 3 and FIG. 4, the infusion of adrenalineresults in a faster initiation of the coagulation process (R shorter),increased amplification and propagation of the coagulation process, i.e.increased thrombin generation (Angle increased) and a clot with anincreased mechanical strength (MA increased).

Example 2

We have identified a pro-hemostatic effect of administration ofsympathicomimetics, as exemplified by adrenaline infusion in 30 healthysubjects (FIGS. 3 and 4), patients prior to surgery (FIG. 7), as well asafter noradrenaline administration in 10 healthy subjects (FIG. 5).

We have found a dose dependent increase in the pro-hemostatic effect ofadministration of sympathicomimetics where a dose of 1 microgram/kg/hourresulted in a smaller change as compared to baseline than 2microgram/kg/hour did and the pro-hemostatic effect was further improvedwhen 3 microgram/kg/hour was administered (FIG. 7). A dose-dependentincrease in MA response was additionally observed in a series ofadrenaline infusion in the doses 3.5, 5.0, 6.0 μg/kg/h (FIG. 4c ).

Example 3 The Effect of Administration of Adrenaline by IntravenousInfusion on TEG Parameters in 10 Consecutive Patients UndergoingProstatectomy

Patients undergoing prostatectomy were anaesthetized by propofol andhaldid. Prior to skin incision the patients received a step-wise i.v.infusion of adrenaline in the doses 1, 2 and 3 μg/kg/h each for 5minutes. TEG analyses were performed as described in example 1, exactly30 minutes after collection of arterial blood. Blood samples wereobtained before and after each dose and 1 hour after discontinuation ofadrenaline infusion. As illustrated in FIG. 7a-c administration ofadrenaline result in a significantly faster initiation of thecoagulations process (R decreased), increased rate of amplification andincreased rate of propagation and thrombin generation (increased Angle)and an increased mechanical strength of the clot (increased MA).Furthermore, the pro-hemostatic effect of adrenaline on clot strength(MA) is abated 60 min after discontinuation of infusion. Importantly, asopposed to other pro-hemostatic therapies such as coagulation factorconcentrates, activated coagulation factor concentrates and activatedrecombinant factor Vila, sympathicomimetics improve clot strength (MAincrease) also in humans with a normal hemostatic system, whereasconventional pro-hemostatics only improve the initiation phase (R) andthrombin generation (Angle).

Example 4 The Effect of Administration of Adrenaline by IntravenousInfusion on Perioperative Blood Loss

In addition to the enhanced hemostatic response, intravenousadministration of adrenaline resulted in a significant reduction inperioperative blood loss. Blood loss of the 10 patients described inexample 2 and 10 additional prostatectomy patients receiving a 15minutes continuous adrenaline infusion of 3 μg/kg/h before skin incisionwere compared to 40 control patients, not receiving adrenaline, whereof20 were operated before the interventions and the last 20 subsequentlyafter the intervention (FIG. 8). Intravenous administration ofadrenaline reduced perioperative blood loss significantly.

Example 5 Safety

The pro-hemostatic effect of sympathicomimetics resulting in increasedclot strength as evaluated by TEG MA could potentially increase the riskof thrombembolic events in the patients. It has previously been shownthat an increase in MA after surgery is associated with increasedincidence of thrombembolic complications (McCrath et al. 2005). As canbe seen in the FIGS. 6 and 7 c and in Example 2, the MA returns tobaseline within 30 or 60 minutes, respectively, after discontinuation ofadrenaline infusion and, hence, no risk for development of thrombembolicevents due to increased clot strength can be anticipated afterdiscontinuation of the drug.

Example 6 Fibrinolysis Resistance

When challenging the clot in vitro by induction of fibrinolyis, theLysis AUC obtained by TEG (see FIG. 2) is a measure of the clot'sresistance against fibrinolysis. Healthy subject received step-wiseadrenaline infusion as described in FIG. 4, and blood was collectedbefore (t=0), immediately after the infusion (t=15) and 30 minutes afterdiscontinuation (t=45). Citrated whole blood was analysed precisely 30minutes after blood collection: The fibrinolysis activator tPA (AmericanDiagnostica) was added in a final concentration of 2.4 nM and TEG wasperformed as described in Example 1 and FIG. 3. As shown in FIG. 9,adrenaline improves the resistance against fibrinolysis by increasingthe Lysis AUC significantly (154%). This effect was abrogated 30 minutesafter discontinuation of adrenaline infusion. This clot stabilizingeffect described above has not been observed when administeringcoagulation factors concentrates (activated or non-activated) orrecombinant factor VIIa.

Example 7 TEG MA in Relation to Combination of Adrenergic ReceptorAgonist and Antagonists

An antagonist directed at the known adrenergic receptors couldpotentially abrogate the sympathicomimetic induced pro-hemostatic effectas evaluated by TEG MA. Healthy volunteers rested 1 hour beforereceiving step-wise i.v. administration of adrenaline in the doses 3.5,5.0 and 6.0 μg/kg/h, five minutes infusion at each dose, as described inFIG. 4. Hereafter the subjects rested for 1 hour and received anantagonist by i.v. infusion propanolol (primarily a β-2 antagonist, 0.15mg/kg for 10 minutes), n=8, Urapidil (α-1 antagonist, 50 mg) or Seloken(β-1 antagonist 0.15 mg/kg for 10 minutes), n=7. The subjects restedanother 30 minutes after receiving antagonist and the adrenalineadministration was repeated as described above. As a control, subjectsalso received repeated adrenaline administration without antagonist(n=6). Blood samples were collected from an arterial catheter atbaseline before adrenaline (0.0) and after each dosing (3.5, 5.0, 6.0)at both adrenaline infusions. FIG. 10 illustrates that MA increasesafter adrenaline administration and that this response was not affectedby β-1 blocking (Seloken). None of the other antagonists testedabrogated the MA increase after adrenaline infusion and showed a similarresponse as depicted for Seloken (FIG. 10).

Example 8 Hemodynamic Effects in Relation to Administration of aCombination of Adrenergic Receptor Agonist and Antagonists

Adrenaline affects the heart and hemodynamic system, primarily throughthe β-1 receptors. In connection with surgery an increased stressresponse is seen due to pain, intubation etc. leading to tachycardia andan increased risk of arrhythmias during surgical procedures. Additionalanesthetics and/or pain relief and/or β-receptor blocking agents areused to reduce these side effects.

The hemodynamic changes comprising heart rate (HR), cardiac output (CO),stroke volume (SV), mean arterial pressure (MAP) and total peripheralresistance (TPR) were monitored during the protocol described in example7 and FIG. 10. FIG. 11 depict the hemodynamic changes in response toadrenaline before and after administration of the β-1 receptorantagonist Seloken. Adrenaline alone increased HR significantly, whereasthis effect was practically abrogated/normalized when Seloken wasinfused (FIG. 11a ) and as the effect of treatment nearly showedsignificance (p<0.052) post hoc separate Bonferroni adjusted pairedt-test was completed showing significant differences in HR at theadrenaline doses 5.0 and 6.0 before and after Seloken. The increase inCO in response to adrenaline infusions (FIG. 11b ) was significantlylower in all adrenaline concentrations when Seloken was administered.The increase in SV (FIG. 11c ) was not significantly lowered afterSeloken administration and no effects on the MAP were detected at any ofthe adrenaline doses used in the described protocol (FIG. 11d ). Asignificant decrease in TPR was observed for all adrenaline doses bothwith and without Seloken with a significant effect of Seloken. SeparateBonferroni adjusted t-tests showed a significantly lower decrease inadrenaline response after Seloken treatment (FIG. 11e ).

In conclusion, infusion of a β-1 receptor blocker almost normalizes theincrease in HR, reduces the increase in CO and reduces the decrease inTPR, seen in response to adrenaline infusion.

Example 9

Three healthy volunteers received 5 doses of adrenaline infusion lastingfor 5 minutes each in the following step-wise increasing doses 1, 3, 5,7, and 9 μg/kg/h. After resting 1 hour, the subjects received Selokeni.v. 0.20 μg/kg for 10 minutes and rested again 30 minutes beforerepeating the step-wise adrenaline infusions. Blood samples wereobtained from an arterial catheter at baseline (0.0 μg/kg/h)), aftereach of the first adrenaline doses, at baseline after Selokenadministration and rest and after each of the subsequent adrenalineinfusions. The blood was analyzed with TEG as described in FIG. 3 andExample 1. TEG MA values are presented as mean with 95% CI.

Plasma K+ concentrations where followed before and after administrationof both adrenaline and Seloken (beta blocker). As can be seen from Table1, the plasma potassium concentrations fell following adrenalineadministration. The drop in plasma potassium concentration was less whenSeloken was administered prior to the administration of adrenaline.

TABLE 1 Plasma concentration of K⁺: Plasma potassium (K⁺) was measuredin the healthy subjects described in FIG. 12 before and after adrenalineinfusion with 9.0 μg/kg/h before and after Seloken administration.Before Before Seloken After Seloken Seloken After After Seloken AfterPerson Baseline adrenaline Baseline adrenaline 1 4.1 3.2 4.0 3.7 2 3.93.3 4.1 3.7 3 4.0 3.2 3.9 3.7

REFERENCES

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1.-89. (canceled)
 90. A method for treatment or prophylaxis of bleedingin a subject with subnormal clot strength and stability, the methodcomprising administration of an effective amount of an adrenergicreceptor agonist to said subject.
 91. The method according to claim 90,wherein the adrenergic receptor agonist is adrenaline or noradrenaline.92. The method according to claim 90, wherein the adrenergic receptoragonist is administered in the range 0.1 to 100 microgram/kg.
 93. Themethod according to claim 90, wherein the adrenergic receptor agonist isadministered in the range 0.1 microgram/kg/hour to 25 microgram/kg/hour.94. The method according to claim 90, wherein the adrenergic receptoragonist is administered in the range 0.1 microgram/kg/hour to 20microgram/kg/hour.
 95. The method according to claim 90, wherein theadrenergic receptor agonist is administered in the range 1microgram/kg/hour to 10 microgram/kg/hour.
 96. The method according toclaim 90, wherein the adrenergic receptor agonist is administeredsystemically.
 97. The method according to claim 90, wherein theadrenergic receptor agonist is administered intravenously.
 98. Themethod according to claim 90, wherein the adrenergic receptor agonist isadministered by intravenous infusion.
 99. The method according to claim90, wherein the adrenergic receptor agonist is administeredcontinuously.
 100. The method according to claim 90, wherein theadministration results in a systemic concentration of the adrenergicreceptor agonist.
 101. The method according to claim 90, wherein thesubject is human.
 102. The method according to claim 90, wherein thesubject is suffering from thrombocytopenia.
 103. The method according toclaim 102, wherein the thrombocytopenia is caused by decreased bonemarrow production of megakaryocytes.
 104. The method according to claim90, wherein the bleeding in said subject is caused by a combination ofcoagulopathy and thrombocytopenia.
 105. The method according to claim90, wherein the subnormal clot strength and stability in said subject isdue to low platelet function.
 106. The method according to claim 90,wherein the subject is suffering from drug-induced thrombocytopenia.107. The method according to claim 90, wherein the subject is sufferingfrom chemotherapy-induced thrombocytopenia.
 108. The method according toclaim 90, wherein administration of the adrenergic receptor agonistincreases clot strength and stability in said subject.
 109. A method fortreatment or prophylaxis of bleeding in a subject suffering fromthrombocytopenia, the method comprising administration of an effectiveamount of an adrenergic receptor agonist to said subject.